One-on-One with Barry Halpern, JD
My law firm practices throughout the western United States, and one of the areas that I see as a general pattern is when … continuity of care becomes an issue. The cases that are sometimes the most troublesome are those in which the hospitalist is involved.
There’s never a real clear demarcation of responsibility between, for instance, the surgery service and the hospitalist. Orders are written and then interpreted by the nursing staff in ways that, in retrospect, even the surgical service or the hospitalist are not pleased with. Yet the physicians aren’t talking to each other, and the documentation in the medical record is intermittent … .
Those kinds of situations, particularly where there is later alleged to have been, for instance, a medication error, become very difficult to defend. Because from the perspective of the lay jury that will be looking at the case, it’s easy for a plaintiff lawyer to depict a very disjointed and uncoordinated approach to care, when—in fact—the reality of practices is that they don’t always go perfectly and things aren’t always documented the instant that they are done.
And sometimes bad things happen despite everybody’s best efforts. But when you have a rough interface between the hospitalist and the other physicians with regard to responsibility for a patient, you are inviting a legal problem.
—Halpern is an attorney with Snell and Wilmer Law Offices, Phoenix
Case #3: A 72-year-old female who was pretty healthy (she had some high blood pressure) came in with abdominal pain. The ED doctor drew the laboratories, which suggested pancreatitis, and then investigated why she had pancreatitis. The ultrasound ordered by the ED doc showed gallstones. The physician then correctly inferred that she had gallstones causing her pancreatitis.
A hospitalist was called [and] admitted the patient. Surgery and GI consultants were called. The GI consultant first ordered an endoscopic retrograde cholangiopancreatography to clean the gallstones from the common bile duct. That went fine, and the next day the patient looked a little better. The GI service said, “Anticipated to go home in a couple days.” Surgery felt the same.
Then the consensus was to remove her gallbladder because eventually she would need to have it done. And that’s when things started to go badly.
On postoperative day two, the patient started having pain out of proportion to what should be expected. The internist (the hospitalist) raised that question in his note. The surgeon said, “No, that’s still postoperative pain,” and increased the pain medicine.
The hospitalist said, “I’m really concerned about this; I’ll talk to the surgeon.”
Again the surgeon said, “There’s nothing to worry about. I’ll at least order a HIDA scan.”
Initially the patient refused the scan, but the next day—postoperative day three—she was still having pain and was clearly worse. She had a high fever; her blood pressure dropped; and her white blood cell count climbed from 10,000 to 20,000, indicating infection/inflammation. Finally the hospitalist ordered a CT scan, which shows a perforation caused by the surgery.
The patient went to surgery for repair. As was predicted, she had a rocky hospital course and ultimately died a month later.
The surgeon was clearly in the wrong. … I was consulted and was asked, “What would you do with the hospitalist? What was their role in that case? Do you think he failed to meet the standard of care?”
—Dr. Baudendistel
Communication with Other Clinicians
“Communication between physicians is critical,” says Sally Whitaker, RN, BSN, risk manager with Rex Healthcare in Raleigh, N.C. “[Hospitalists] shouldn’t just rely on knowing they’ve put their notes on the discharge summary.”