I really have no words for how stupid this ruling is. It establishes that any physician that has an opinion on a case, whether or not they've officially been consulted and accepted the patient as one of theirs, whether or not they've actually got formal power over the patient's care is now liable for the course of care.
Picture this scenario:
NP stops a doc in the hallway and asks, "Can I give this patient amoxicillin for their UTI?" Simple question, simple answer.
The physician cannot answer, because simply having been unofficially asked a question about the proper course of care has now made them liable. Saying "I can't speak to you" actually does not alleviate them of that liability, it's just withholding care. And any answer creates liability, so they need to go do a full consult on this patient, to at least offer a defensible response.
Who has the time to do a full evaluation of every patient someone is asked about indirectly? And does a patient have to pay for a consult created by someone asking a minor question?
So either the docs are twice as harried as they are now - which they don't have the capacity for, so this is a false choice - or medical staff are no longer allowed to ask doctors questions. Bonus points for all the involuntary increase in healthcare spending.
My lawyer wife asks, what if it's couched as a hypothetical?
Well, I ask, if this went to trial would any jury believe that the physician really believed they were being asked a hypothetical? No, she says. Well then that doesn't help.
Congratulations, Minnesota. Once this makes its rounds among physicians, you're going to have docs getting pissy and telling people not to ask them questions, because just the act of asking is creating liability. Never mind just how much day-to-day care is lubricated by curbside consults and hallway questions. Turning all of those into official consults... jeez.
I can't imagine anything more liable to slow down care and inflate costs without meaningfully improving outcomes. That judge had no idea what they were doing.
I don't think it's nearly as dire as that (but I'm not a medical professional).
Maybe this lawsuit shouldn't have gone this way, and the NP apparently shouldn't have tried to avoid sending the patient to the ER, but it seems to me the takeaway is a doctor shouldn't make a firm admit/non-admit decision based on partial lab results. Refuse non-emergency admission based on inability to properly evaluate the patient once it's clear the NP doesn't agree with your opinion, and point the NP to the ER otherwise. Also point out that if the patient in this case really did have a serious infection, avoiding the ER would be bad and slow down essential treatment anyway, and it would actually harm the patient for a non-ER doc to admit them.
Everyone agrees that there are lots of subtle things about a patient which a medical professional can pick up on that are not clearly shown in lab results, right? Wouldn't it have been obvious from the described phone conversation that the nurse's spidey senses were telling them something? "Clearly we're seeing different things; I don't feel comfortable admitting this patient through this channel. If you think I'm missing something and this is an infection, the ER is the right channel for that anyway."
I think there's plenty of blame to heap on the clinic, too. Does anyone think the NP, after questioning the decision of both docs, just casually decided not to send the patient to the ER?
The calculus was almost certainly: "two doctors told me I'm wrong, so I don't have much personal liability here, and there may be negative career consequences if I send this patient to the ER and I'm wrong."
> I don't think it's nearly as dire as that (but I'm not a medical professional).
Then you don't know how wetting-themselves-terrified most physicians are of malpractice. It builds itself into how people practice on a daily basis. I'm considered relatively "bold" among my peers in my inclination to practice what I think best serves my patients rather than covering my ass, and even I'm reading this as "if I lived in MN, I'd be leaving MN."
> Maybe this lawsuit shouldn't have gone this way, and the NP apparently shouldn't have tried to avoid sending the patient to the ER, but it seems to me the takeaway is a doctor shouldn't make a firm admit/non-admit decision based on partial lab results.
It's just an irrelevant discussion. It's like blaming the janitors for making a non-admit decision. Emergency care goes through the ED, period, no "decision" is involved in the process.
>and point the NP to the ER otherwise. Also point out that if the patient in this case really did have a serious infection, avoiding the ER would be bad and slow down essential treatment anyway, and it would actually harm the patient for a non-ER doc to admit them.
It's really not a doc's place to explain to people "how ER's work," and "basic clinical reasoning" (how and when to escalate care is clinical reasoning. It's a big part of what med students learn in the second half of med school.) If you explain that to people, you quickly become the massive asshole doc that people talk shit about behind their back. If you do it to an NP, all the nurses will be trying to eat your liver. As it is, he was only one of two docs that day to explain to her that diabetic episodes cause white counts, so he was already going to be having a tense exchange in which she didn't know basic internal medicine and was having it explained to her by "an arrogant doctor." Traditionally, responsibility for basic clinical reasoning sits solely with the physician in charge of making the call. If NPs want to practice like physicians, they can join us in taking full responsibility for the decisions they make.
> Everyone agrees that there are lots of subtle things about a patient which a medical professional can pick up on that are not clearly shown in lab results, right? Wouldn't it have been obvious from the described phone conversation that the nurse's spidey senses were telling them something?
I want to be clear again: she is practicing independently. She's not a subordinate reporting information that he is failing to take seriously enough. She is, theoretically, a colleague getting a curbside. She gets his opinion, and she can do with it what she wants. That's how consults work in all of medicine.
Second, a conversation that opens with "doesn't understand how the ER works," and "doesn't understand white counts in diabetes" (I really can't stress how absolutely fundamental, medicine 101 this is), doesn't lead to you thinking "Gosh, I must be missing something, because she seems concerned." It leads to you thinking, "This person is a fucking moron."
> I think there's plenty of blame to heap on the clinic, too. Does anyone think the NP, after questioning the decision of both docs, just casually decided not to send the patient to the ER?
I don't know if it was casual or not, but since it was completely her call whether or not to do it, apparently "yes."
> The calculus was almost certainly: "two doctors told me I'm wrong, so I don't have much personal liability here, and there may be negative career consequences if I send this patient to the ER and I'm wrong."
You don't have negative career consequences for sending patients to the ED anywhere I've seen. It's the universal CYA: worst case scenario, send them to the ED, you can't be blamed. And of course she still has personal liability: she's the clinician making the call (which is why she got sued and promptly settled). If 30 doctors who aren't in charge of her tell her she's wrong, it doesn't matter. The docs who shot her down weren't in charge of her. They were just opinions, and don't shield her from anything.
(That said, a third doc has reviewed the medical records - granted, for the defense - and justified the call the first two docs made. I'd point out the criticisms of the suitor's expert witness, but they don't have one.)
> how and when to escalate care is clinical reasoning. It's a big part of what med students learn in the second half of med school.
Which NP's don't have as much of, since they didn't go to (or at least didn't complete) med school?
Assuming the court got it wrong and it should be 100% legally the NP's fault. Why did she do what she did? I can't make sense of it in the absence of external factors.
Why would she needle two docs about their diabetes diagnosis, obviously disagreeing with them, and then not send the patient to the ER? If it was clear to her that she shouldn't trust their opinions since she's ultimately responsible, why wouldn't she send the patient to the ER just to be safe? Whether or not she's incompetent for not knowing elevated white blood cell count could be caused by diabetes, she didn't miss anything; she clearly had concerns, and they ended up being empirically correct (even if by luck). What motivation would she have not to act on them?
Is sending a patient to the ER more trouble than trying to admit them through other means? I have no idea, but I'm guessing it's unlikely. Would a clinic nurse have to fill out any substantial paperwork, or merely tell the patient to go to the ER and write that on their chart?
You say you've never seen it, but perhaps there was something wrong with the clinic's policies, and there were incentives for her not to send too many patients to the ER who end up not getting admitted?
What other explanations are there? If she wasn't concerned, why did she needle the two doctors? If she was concerned, why didn't she send the patient to the ER unless there were misaligned incentives or she didn't actually realize it was her call? Maybe some of the details are buried in the out of court settlement with the clinic?
>Which NP's don't have as much of, since they didn't go to (or complete) med school?
This is a very politically sensitive question. I'll answer bluntly, because yay for pseudonymity - no one will answer you this bluntly in real life anymore.
The road to NP is a bachelors in nursing, being a nurse for a little bit (increasing numbers of programs don't require nursing time, so as to be more competitive with PA programs) followed by some (fairly easy) grad courses, followed by being an NP. In some states this requires supervised practice; in others, it leads to independent practice. As an aside, "supervised practice" isn't - hospitals hire NPs to be cheap manpower that does an end-run around physicians, so they use them to their maximum and, in effect, they end up unsupervised.
Nursing is not "doctoring light," it is its own thing (keeping an eye on patients, administering medication, taking vitals, measuring ins and outs, changing dressings) so while it provides exposure to the clinic, it does not provide exposure to clinical reasoning. You pick up things like "CTPA to catch a pulmonary embolism," basically enough to do monkey-see monkey-do medicine, but again ... not to reason. So you miss exceptions, you miss uncommon things, you miss subtle things, you miss contingencies. Honestly, docs that go to malignant residencies (residencies that just use trainee physicians as cheap bodies rather than trainees) end up something similar.
NP courses do not make up this difference even a little bit. Columbia's school of nursing is a big proponent of NPs being the equivalent of physicians. They attempted to administer the first of three physician licensing exams to their NP students and the pass rate was less than half that of the worst med schools in the country.
An NP is basically an under-educated medical student. And a medical student is someone too ignorant to be allowed near a patient - that's what residency training is for.
PAs are substantively similar. Their coursework is a lot more similar to med student coursework, but they skip out on the back half of med school. Some PA programs are three years and cover at least some clinical reasoning; some are just a bit over two years, and don't cover any at all. They also don't do residencies.
So, basically: if you wouldn't want a freshly graduated medical student on his first day of residency treating you, you don't ever want an NP or PA being in charge of your care.
And they often are. Hospitals not-infrequently hire a doctor to act as a malpractice license, and then they stock up so many PAs under the doc that the doc never actually has the chance to supervise.
In practice, I do prefer PAs. For social and political reasons, NPs often end up working closely with other nurses and NPs, and PAs tend to end up working more with the physicians (despite, at least fresh out of training, the two being completely interchangeable). The NPs end up spending their time with people that can't teach them any clinical reasoning, whereas the PAs get taught alongside the med students and residents. Even though the PAs usually don't spend an extra 40 hours a week studying like a med student or cramming like a resident, they at least pick up some stuff during their shifts.
It's not the med school that really makes the difference. It's the residency. Med school is what gives physicians the ground level knowledgebase to go spend four or more years working 80+ hours a week (plus studying) intensively training. Mid-levels have less training, it's true, but the key difference is that they have no residency. Even hours worked are apples-to-oranges: an NP shift is about knocking out paperwork, a first year resident shift is about seeing all the patients and knowing all the things because your attendings will constantly be hounding you about them and you'd better know your assitis from your elbowitis, you'll be writing treatment plans and they'll be ripping them to pieces (or, hopefully, not).
The other thing is just personality. The people who are driven to study their asses off day-in and day-out for a decade are not the same people who get a bachelors in nursing and go take blood pressures and hand out pills. It's an enormously different pool of people. NP becomes about getting independence and a pay-raise, but it draws from the average nurse crowd.
Bottom line: when physicians and mid-levels and healthcare executives get sick, they go to physicians. That people who aren't insiders get mid-levels foisted on them is a crime against the public. "You don't know any better, and we don't have a better way of making our profit margins, so you get people who aren't educated enough, aren't trained enough, and aren't supervised or held accountable to look after you. Of course, if you've got money and you know the system, you can have a real doctor."
(There are some mid-levels I love. They tend to be the ones who have worked in one little niche forever, and take their shit super seriously, and go out of their way to study and read like they're physicians. I most often see this in critical care PAs. I fucking love them.)
No one in healthcare is allowed to say this anymore. Hospitals need mid-levels in order to make profit margins. Insurers want you seeing mid-levels (they actually advanced the term 'providers' to muddy the water between physicians and non-physicians) in order to minimize healthcare costs. Any doc who says any of this out loud is "not a team player" (read: getting in the way of our minimizing our expenses).
I'm not an old-school doc, either, talking out of nostalgia and bias. I'm a second careerist who came to medicine after working at the executive level in health insurance, often working on cooperative agreements with large physician groups. I've seen this from the other side.
As for clinic incentives: I don't know. Any incentives against sending the patient to the ED would apply even moreso against sending them to admit to another hospital's inpatient service, so that doesn't make sense. Especially since the other hospital was in another hospital system, so it's not like her hospital would get dinged for the cost of a readmission or something. And, as you say, if she wasn't concerned, why bug two doctors? If she was concerned, why not send them to the ER?
My suspicion is this: he's a shit clinician. People who can't reason about what they're seeing don't tend to stick by their guns, because they're already making decisions by gut and habit. So, he saw a sick patient and got concerned and made some calls. He wasn't taken too seriously because the labwork was probably not too dire and/or he didn't report all the relevant values and/or because he came off like an idiot, so the "just take my word for it, this patient looks like shit" line that I'll buy from someone whose clinical judgement I trust got ignored. So, two docs told him the patient didn't sound like they needed inpatient care. And because they learned medicine by monkey-see monkey-do to begin with, and they didn't have enough clinical reasoning to make a cogent argument to themselves as to why they'd ignore the monkeys, went against their own judgement.
It's easy to overpower someone's judgement if they don't have judgement to begin with, just habit and gut feeling.
Thanks for your comments. They're very enlightening.
So your thesis is that people should see real doctors for anything that might be serious. Fair enough. But some serious things present as possibly non-serious things that a clinic NP should handle with outpatient treatment, right? Including a case like this that might be easily treatable diabetes symptoms, or might be a serious infection that will kill the patient in 24 hrs? For clarity, this was not just an unusual lab value or two; the appeals court decision says the patient's initial symptoms were abdominal pain and fever [1].
Here's the point, I think: The NP, with her limited medical training, wasn't sure which side of the line this fell on. Two doctors told the NP that they thought the patient's symptoms were caused by diabetes, and by not taking action or encouraging her to send the patient to the ER, both doctors implied that it should be handled outpatient, and not involve a real doctor.
From the decision:
> Simon says that Dinter told her that Warren did not need to be admitted to the hospital. Dinter disagrees, saying that he responded “to what end[?]” to a question as to whether Warren should be admitted.
As you point out, nurses and NPs do not have a doctor's training. Suppose you were a GP or hospitalist and had a patient call you directly for some reason and you listened long enough to hear they had abdominal pain and fever and (modestly) elevated WBC. Would you tell them it's probably caused by diabetes, even if that's what you think? I doubt it. You wouldn't admit them yourself even if you could, right? But you'd tell them if they felt it was serious to get the hell to an ER and let them evaluate it, right? Given your view on lack of training of NPs, why treat them any differently than patients?
It's beside the point that the NP probably should have ignored the hospitalist's attempt at gaslighting ("to what end?") and sent the patient to the ER anyway. If doctors agree that NPs are not competent to be diagnosing as they currently do, then why discuss a patient's diagnosis (for the purposes of admission) with them as if they're a doctor and can competently make their own judgments? Remember this is all in the stage where the patient doesn't really have a doctor yet.
On reflection, I guess it's possible this is a case where competent doctors would genuinely think, because of details beyond what's reported, that it was diabetes... until it was too late. Maybe any other nurse would have thought so too, and not pursued trying to get the patient admitted at all. Maybe this was a statistically unlikely "lucky" (in the sense of being correct, in hindsight) gut feeling this NP had, which led to disagreement and opened the door for a juicy settlement? And perhaps this is all pointless, holding doctors and medical networks, as well as the nurse herself, responsible for a nurse's lucky guess that wasn't followed through on?
To hopefully quell some of your fears about the state of practicing medicine now in MN, let me quote:
> Our decision today should not be misinterpreted as being about informal advice
from one medical professional to another. This case is about a formal medical decision—
whether a patient would have access to hospital care—made by a hospital employee
pursuant to hospital protocol. We decide only that hospitalists, when they make such
hospital admission decisions, have a duty to abide by the applicable standard of care.
You are the only person making sense in this thread. Michael Crichton was right about journalism. It's crap and you only realize it when it covers something that you know in-depth.
I really have no words for how stupid this ruling is. It establishes that any physician that has an opinion on a case, whether or not they've officially been consulted and accepted the patient as one of theirs, whether or not they've actually got formal power over the patient's care is now liable for the course of care.
Picture this scenario: NP stops a doc in the hallway and asks, "Can I give this patient amoxicillin for their UTI?" Simple question, simple answer.
The physician cannot answer, because simply having been unofficially asked a question about the proper course of care has now made them liable. Saying "I can't speak to you" actually does not alleviate them of that liability, it's just withholding care. And any answer creates liability, so they need to go do a full consult on this patient, to at least offer a defensible response.
Who has the time to do a full evaluation of every patient someone is asked about indirectly? And does a patient have to pay for a consult created by someone asking a minor question?
So either the docs are twice as harried as they are now - which they don't have the capacity for, so this is a false choice - or medical staff are no longer allowed to ask doctors questions. Bonus points for all the involuntary increase in healthcare spending.
My lawyer wife asks, what if it's couched as a hypothetical? Well, I ask, if this went to trial would any jury believe that the physician really believed they were being asked a hypothetical? No, she says. Well then that doesn't help.
Congratulations, Minnesota. Once this makes its rounds among physicians, you're going to have docs getting pissy and telling people not to ask them questions, because just the act of asking is creating liability. Never mind just how much day-to-day care is lubricated by curbside consults and hallway questions. Turning all of those into official consults... jeez.
I can't imagine anything more liable to slow down care and inflate costs without meaningfully improving outcomes. That judge had no idea what they were doing.