Assume you have a mostly elective practice. You still have hospital privileges, but most work you do is performed in an outpatient surgery center. You are technically on the call schedule. You rarely get called. Most calls can be handled by having the patient see you in your office the following day. Until…
A patient presents with purulent drainage related to one newly placed breast implant. You didn’t perform the original surgery. Another surgeon did. The ED tried repeatedly to get in touch with that surgeon. To no avail. The ED is just getting voicemail and a message stating, “If this is an emergency, hang up and dial 911.”
You see the patient. Remove the implant, perform a washout, and admit for antibiotics. The patient is soon discharged.
You leave a couple of messages for the original surgeon. He never calls you back.
You’d like to have the patient return to the original surgeon. But he’s MIA.
You were just helping out. Doing a good deed. Can you terminate care?
The short answer is not really.
You were on the call schedule. You had a contractual obligation to provide services to the ED. You discharged your duty.
Once you established a doctor-patient relationship, that relationship continues until one of several events takes place.
a. The patient decides to seek care elsewhere.
b. You transfer care to a doctor willing to accept the patient, and the patient agrees.
c. You terminate the doctor-patient relationship.
If you terminate the relationship, you cannot just abandon the patient. You must give the patient sufficient notice. Generally, that entails continuing care for 30 days or until the patient locates another physician, whichever comes first. Such care is generally limited to urgent or emergency conditions. Of course, that definition will be viewed through the patient’s lens. Also, you need to tell the patient how to locate a new physician – such as the County Medical Society website or to the patient’s carrier’s in-network roster. And you need to explain you will make records available to the new physician once the patient signs an authorization form. This would be a formal process.
Importantly, you should be careful about terminating the doctor-patient relationship in the middle of a treatment plan.
In the vignette above, it would not be a good idea to send the patient the 30 days’ notice letter as soon as she arrived home. There should be a reasonable transition period.
It’s unfortunate that the original surgeon abandoned his patient. That may be an issue for the Board of Medicine to pursue.
But, from your perspective, this is your patient until the baton has been properly handed off.
What do you think?
I was told you can’t terminate the relationship in the midst of treating something. That may’ve been the liability carrier telling me that, or the State Board, or both. The patient still needs to be seen post-discharge, and guessing oral antibiotics were prescribed at discharge, and instructions to follow-up, it seems this is yours until the medical (or in this situation surgical) problem is resolved?
I don’t relish reporting colleagues to the SMB, but this original surgeon was wrong.
Edit: unless something bad happened to the original surgeon…
This is horrible. The second surgeon is put in a no win situation. The first surgeon has an obligation to be on call, or to have an associate on call. The second surgeon had to do this procedure. This patient will probably be unhappy. Will she be unhappy with only the first surgeon? Will this patient also be unhappy with the second surgeon? The best thing, I think, is for the second surgeon to manage this patient thru this problem. And to be extra nice and supportive to this patient. Its best not to be critical of the first surgeon. Eventually, the first surgeon will be involved in her post op care and all will be fine with the second surgeon.
Richard B Willner
The Center for Peer Review Justice
This isn’t an uncommon situation. I see this frequently where the patient gets a surgery at a surgicenter and the patient shows up to a nearby ER with acute bleeding, etc. and the on call person has to manage it. It is tough to terminate especially if the original surgeon can’t be found.
1)It is unknown what happened to the original surgeon. When I was a surgical resident decades ago, it was drilled into us that a surgeon could not just do surgery and go on vacation a day later. They had to be around for a reasonable recovery period after the surgery. Today with more group practices and hospital employed physicians, the surgeon should have someone able to cover them when they are gone. This was also why the ACS actively discouraged the itinerant surgeon that came, did some surgery, and then left town.
What happened in this instance to the first surgeon? We can only speculate. Was this MIA surgeon, on vacation, ill, out of the country, deceased? We do not know. Was the surgeon reachable through their office during regular office hours, but this emergency was on a weekend? We don’t know.
2)Once this patient presents and it is an emergency, and it is an area of medicine that you have competency in, AND have privileges for, then you are obligated to treat this patient.
However, if an OB/GYN has now limited his practice to GYN, dropped his malpractice coverage for OB, AND dropped his OB practice privileges from his hospital privileges, then he is under no obligation to provide OB care and the patient must be transferred to a facility that does provide such care. There are significant limitations to what an on call physician can refuse, depending upon whether or not it is truly an emergency.
Here is an example from the ER that I am aware of from decades ago. An ER doctor decided, on his own, without consulting anyone else, that a patient with simple pneumonia, was going to be admitted. He proceeded to call all of the family physicians in town. None would accept the patient as an admission, not even the family physician on call, because the patient was a known drug addict, and had verbally abused the office staff, and family practice physicians, of every such office in town. He was well known to everyone. The ER doctor then called the chief of staff, who was not a family physician. The ER doctor wanted to admit the patient to the chief of staff’s service. He was an anesthesiologist. He listened to the patient’s symptoms, vitals, etc. and he felt that the patient did not even require admission. The ER doc was under pressure from administration to admit everything he could that walked through the ER door. The anesthesiologist could not technically admit the patient either. What to do. The ER doctor convinced the consulting pulmonologist who rounded at the facility once a month to admit the patient. Was this an emergency? No. The patient’s vital signs were normal. Could the ER doctor transfer the patient under EMTALA? No, because it would have been dumping. Could the ER doctor have discharged the patient in that circumstance and had them follow up with a family doctor in their office? Sure. As a walk in.
3)In this case a patient with a wound abscess needed treatment. The surgeon on call is on the hook.
He should absolutely refrain from criticizing the operating surgeon. These things do happen even under the best of circumstances. Did the surgeon have the skill to remove a newly implanted breast implant, that was not encapsulated. Yes. If this had been in place long term, and it was encapsulated then the general surgeon might not have been able to do this surgery, as he might not have done such a case in his career. In that instance the patient would have needed to be transferred to the care of a plastic surgeon. But assuming that this was a fresh surgery, then a general surgeon would have the skill to drain the abscess and remove the implant and place a drain. The surgeon would then be obligated to provide care until the patient was healed. Abandoning such a patient or attempted to transfer their care would not be appropriate. That would wind up getting everyone sued, including the original surgeon, ER doc, hospital, and the new surgeon. Compassion dictates caring for the patient as though they had a new onset illness.
4)It would be very interesting to find out where the original surgeon was off to. It also would help to know if the surgeon was simply away for the weekend, and that was the reason he was not answering calls.
5)I was called once, from the ER, decades ago, to intubate a patient. I was not on call. I was also 3000 miles away at a conference, and there was a covering person. I directed the ER to contact that person. I was surprised that they called me, because they did have the call schedule. I was polite, redirected them AND explained that I was 3000 miles away. Had I not explained that I was not in state, all kinds of problems could have reigned down on me.
One has to take these situations carefully and act appropriately.
There are all kinds of legal pitfalls that can swallow up physicians who are not well versed in the requirements for each different circumstance.
The on-call surgeon was in what looks like it was a God Samaritan situation. He had to do what was best for the patient. The conversation between him and the patient would have been interesting. S
he had j just gotten her new implant and now it was her enemy–a foreign body infection. Safe to assume that her feelings included anger, fear, disappointment, and l likely more. Who knows how she felt toward the surgeon who removed it? Gotta be an uncomfortable position for him to have been in.
C’mon, Jeff–tell us about the MIA original surgeon. Surely you have the deets on nit by now.
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Some states have their own laws governing the doctor-patient relationship. In Pennsylvania, for example, a physician is theoretically obligated to care for a patient until either the patient is cured or dies, or the doctor dies.
That was one argument used against me in the single med mal case against me in my career. It failed to persuade since I hadn’t abandoned the patient–rather had offered to treat him if he came to where my primary practice was. I had treated him as a visiting surgeon. The family wanted me to return to treat him further. I didn’t want to badmouth the medical center where I had treated him, but it was woefully deficient and negligent. And they refused to let him come to Alabama. The jury was unconvinced of any wrongdoing. The first appeal failed, as did the second. They finally conceded defeat.