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Minnesota court decision means doctors can be sued by patients they don't treat

123 points by scripthacker 7y ago

maxxxxx 7y ago
Makes total sense to me. If you have the power to decide on the treatment and hospital admission of a patient you have a patient-doctor relationship. If they want to reject responsibility they also should not have stated an opinion without seeing the patient.
- amputect 7y ago
  Yeah I came here to write more or less this exact comment -- the doctor absolutely did make a medical judgement on the patient, and frankly it was an astonishingly bad one. To declare, sight unseen, that a patient with several severe signs of infection is simply prediabetic, is negligent in the extreme, especially when the medical professional who is actually with the patient doesn't agree.
  - amputect 7y ago
    Also I'd like to point out that the headline is, at best, highly misleading -- the doctor didn't see the patient, no, but that's the problem not an exculpatory factor. This isn't a random doctor being sued by a random patient it's a doctor whose medical judgement arguably led to the patient's death.
  - maxxxxx 7y ago
    I am sure they dream of AI diagnosis. It can be optimized for profit and any negative effects can be blamed on the AI.
    - ska 7y ago
      It's more the other way around, at least in a US context. Concern of the impact of AI/physician disagreement is a problem from a malpractice point of view. Physicians in the US have a huge amount of professional leeway - hence the expansion of off-label use - but this is counterbalanced by a large amount of professional responsibility/liability.
  - hn_throwaway_99 7y ago
    Moreover, the Dr's argument that he was just "giving an opinion", but did not actually accept or prevent her admittance, absolutely does not pass the smell test. He was in a position of power, and from the description of the phone call with the nurse practitioner in the article it is extremely clear he wasn't just "offering an opinion", but was in fact denying admittance. Honestly, I feel awful for the patient and her family, but I also feel awful for the NP who tried to do the right thing but was shot down by those with greater seniority than her. I hope her employer changes their training so that if something like this happens in the future that they just tell the patient to go directly to the ER.
    - Scoundreller 7y ago
      And to better assert the independence of NPs. At least with this lawsuit and settlement, NPs may be more legally motivated to do the right thing.
      - arkades 7y ago
        The NP in this story is one of the people that fucked up. A, because she should have sent them to the ED. B, because hospitalists have nothing to do with the ED, and she was trying to /bypass/ the ED. C, because she didn't need her supervising physician's permission to send the patient to the ED. D, just for kicks, diabetes absolutely causes a white count bump, especially during uncontrolled episodes, with the degree of one correlating to the other - something every med student is expected to know, and it's ridiculous that the NP didn't. "Legally motivated to do the right thing"? She's significantly more guilty than the hospitalist, who is a red-herring in this entire discussion ("I'm not the ED attending. Send her to the ED. The ED attending decides who gets admitted for non-elective admissions. Also, she might need urgent care, so she shouldn't wait the 12-24 hours hold-up that would occur if I admitted her directly." would have been the response of any hospitalist I've worked with) and yet he's vulnerable to a malpractice suit, and the NP is not. What legal motivation?
        Scoundreller 7y ago
        I dunno how independently NPs can practise in MN. Sometimes they’re always under an MD and anything that happens is that MD’s responsibility. This can be relatively more true if they’re an employee vs. a contractor (at least where I live, dunno about MN). The NP settled their case out-of-court. So they were held liable, and we don’t know how much. The consulted MD felt like fighting it in court, and lost. That’s what makes this case a bit unusual because something bad happened and one person involved thought they weren’t accountable.
- arkades 7y ago
  I don't want to spam the thread by posting my comment all over it, so I'll ask you to read it downthread. The article highly mis-represents appropriate and routine procedure; the statement that the hospitalist here had the "power to decide on treatment and admission" is factually incorrect, though it's an incorrect impression the article very much tried to leave you with.
- TazeTSchnitzel 7y ago
  I don't know how it works in US law, but it reminded me exactly of the English tort law concept of “duty of care”, which can exist between two people even without direct contact.
- jdoliner 7y ago
  > they also should not have stated an opinion without seeing the patient. Doesn't that mean that the doctors choices basically boil down to 1) see every patient that you get a phone call about or 2) don't take phone calls? Given that I don't think 1 will scale very far it seems like most doctors will have to take option 2, I'm not sure if we're better off in a world where this type of consultation can't happen anymore for fear of liability.
  - LoSboccacc 7y ago
    it's not either or, there's option 3 "I can't form an opinion over the phone, if your medic thinks this can't wait for standard admittance channels I kindly defer you to the emergency services." and likely others.
    - smackinglyt 7y ago
      Unfortunately, it's more complex than that. I'm a hospitalist at a pair of community hospitals that don't have some services (cardiology, vascular surgery, neurosurgery, ophtho, etc). I'm used to calling the specialist at our associated academic center when a possible acute problem related to those specialities may be happening. If those specialists now refuse to do "curbside" phone consults because they can't see the patient and now can get sued, these patients are in a bad position. The tertiery hospitals here are constantly full and I can't transfer patients that don't have immediate true emergencies. This opinion is a major loss for patients. And I also used to "decline" direct admissions based on phone consults, telling outpatient AP/NPs what I thought would be a reasonable course of action and follow-up. Will simply say "sorry" on the phone now and tell them to send the patient to the ED, where the costs are very high. This will simply jack up the cost for everyone else. Not saying the MD in the news article had a reasonable opinion. But spend a single day with me in our busy hospital, see just how tricky this profession is, and you might be convinced that I need more legal protection, not less.
      - scott00 7y ago
        In the event a primary care/urgent care doc disagrees with a hospitalist on the need for admission, why is sending them to the ED the right move? I was under the impression the ED is mostly for triage, and it seems like patients in this situation have already been triaged. It also seems like the sort of disagreement about the need for admission between urgent care and hospitalist is also going to happen sometimes between ED docs and hospitalists. How do those disputes get resolved?
Scoundreller 7y ago
I can’t figure out why the Nurse Practitioner didn’t send the patient to ER? Are direct admits to hospital that bypass ER common outside of, say, fractures or elective surgery?
- maxxxxx 7y ago
  I bet it's because they system is very hierarchical. Once a doctor says something the nurse can't really override it.
  - teej 7y ago
    The hospitalist is acting as the “gatekeeper” to admission here, so they decide if the hospital will take the patient or not. That doesn’t stop the NP from shipping the patient straight to the hospital’s ER. By federal law, emergency rooms must see every patient who comes in their doors.
  - rustybelt 7y ago
    The NP absolutely could have sent the patient to the ER. The vast majority of patients admitted to a hospital come in through the ER.
    - maxxxxx 7y ago
      From what I know about hospitals the NP is supposed to defer to the doctors.
      - Scoundreller 7y ago
        I think there’s big variation state-by-state in terms of NP independence.
    - SolarNet 7y ago
      I think the problem is she brought it to her organization's doctor that often does the ER admitting in situations like this and that doctor overruled her. The NP could still have done it, but it would have been against two different doctors and the organization who employs her practices. The sad thing is that this probably happens often, this is just the first time someone sued over the death.
toomuchtodo 7y ago
Mods: Original title of piece is "Why Did Susan Warren Die?". Can we get it updated to be less sensational? TLDR: A “curbside consult" establishes a physician-patient relationship. EDIT: Mods have spoken. Can't delete due to replies, feel free to ignore.
- teej 7y ago
  The judgement specifically states that this is more than a curbside consult.
- SiempreViernes 7y ago
  I feel the story told by article deserves a fairly sensational title! I do agree that the current title is sensationalizing the wrong aspect though, something like "Minnesota doctors routinely ignore diagnosed treatment" would more apt.
  - toomuchtodo 7y ago
    I agree.
- brlewis 7y ago
  Mods asked a question, not rendering final judgement: https://news.ycombinator.com/item?id=20205224 https://news.ycombinator.com/item?id=20205224 I'd still like to see a less sensational headline and replied there.
edaemon 7y ago
For what it's worth, the submission title ("Minnesota court decision means doctors can be sued by patients they don't see") does not match the article's title, nor does it really match its argument. From the article: >The court concluded that Justin Warren did not have to prove that his mother was in a doctor-patient relationship with Dinter in order to proceed to trial. This was unquestionably the correct decision.
- dang 7y ago
  The article title is baity, so the submitter correctly changed it in accordance with the site guidelines: https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html. I'm not clear on how the title doesn't match the article? It's consistent with language in the opening paragraph. I changed "see" to "treat", though, since that's more specific.
  - SiempreViernes 7y ago
    The main message of the article is more about how doctors routinely deny admission of patients to their hospitals without actually seeing them, and how this is a very strange practice that in this case might have lead to an avoidable death (and certainly to a more agonizing end as no palliative treatment was possible). The title speaks only of the fairly common sense ruling that actively denying admission constitutes a clinical decision
  - edaemon 7y ago
    I don't think the title here needs to be changed significantly, I was just pointing out that it implies something different from the article contents. The title paints the court's decision as if it's about treatment while the decision is actually about assessment. Going by the title one could think anyone could sue a doctor despite never interacting with them, while the article explains that this decision allows you to sue if you are actively refused treatment based on a doctor's assessment (the implication being that the doctor was wrong when they refused to admit/treat you). Perhaps a better title would be something like "Minnesota court decision means doctors can be sued by patients they refuse to treat".
Glyptodon 7y ago
I think the submitted headline is misleading. It's more accurate to say "doctors can be held accountable for medical decisions they make without even seeing a patient."
- Gibbon1 7y ago
  It's misleading because the doctor did look at the blood test results and the patients history and then made a decision to refuse appropriate care. What I think contrary to what a lot of doctors believe[1] the license comes with a large amount of duty. [1] And definitely what the suits that run hospital chains believe.
jawns 7y ago
I think it really hinges on whether this is a "curbside consult" or an actual denial of service. Based on the facts details in the post, it is at least arguable that the conversation between the NP and the doctor was merely a consultation on a diagnosis, which medical professionals do among themselves all the time, and not an actual denial of service. Simon, the NP, described the symptoms to Dinter, the MD, and he gave his opinion -- which turned out to be a really bad opinion with deadly consequences. But I think it could be argued that it is ultimately the responsibility of the NP or doc who is actually treating the patient, not any physician she might have consulted (and especially not one who has not actually seen the patient), to recognize when she's being given horrible advice. And it seems as if she did recognize that it was horrible advice, but wasn't willing to overrule it and send the patient to the ER against Dinter's advice. The post says that Dinter implied, during his conversation with Simon, that it would be pointless to admit the patient. But does that mean he _refused_ to admit her? It seems to me that there's at least arguably a difference between the two, and that his conduct did not actually constitute a refusal of service.
- SiempreViernes 7y ago
  > Dinter also implied that it would be pointless to admit the patient. But does that mean he _refused_ to admit her? He said it in the context of someone explicitly asking him to admit a patient, of course it's a refusal! The most commons way to refuse to answer questions likewise doesn't explicitly involve shouting "I refuse" loudly.
  - jawns 7y ago
    Let's agree that a reasonable person would see that as a refusal. In fact, let's make the refusal even more explicit. Let's suppose that he flat-out said, "I don't think she needs emergency care, and if you send this patient to the ER, I will refuse to treat her." Even so ... isn't it ultimately on the NP -- who seemed to grasp that he was blowing her off -- to either get a second opinion or (ideally) use her own medical training to determine that the patient really should go to the ER, no matter what he says, knowing that he can't actually refuse to treat her? Stating that you intend not to do something, after all, is not always the same as actually refusing to do it. That's not the most compelling argument, I know. But I do worry about the broader implications of this ruling. Should physicians fear malpractice claims arising out of consultations with colleagues? In what cases can you feel free to give your opinion "off the record," with the understanding that the person who has consulted you will bear ultimate responsibility for the treatment they are providing?
atourgates 7y ago
The other (IMO very critical) factors this doesn't address is the relationship between midlevel providers and MDs, and the shift towards away from primary-care providers and specialists treating their patients during hospitalization to hospitalists treating patients during hospitalization. 30 years ago, the patient likely would have seen their family doctor, who would have caught the symptoms of sepsis (just like the midlevel nurse practitioner did), and then directly admitted the patient into the hospital themselves, and cared for the patient during their admission. I grew up with a father who was a primary care physician in a rural community. If one of his patients required admission to the local hospital, he'd admit them directly. It was normal that on Saturday and Sunday mornings, then-6-year-old-me would tag along as he rounded through his patients in the hospital. He'd manage their care, talk with them about their symptoms and progress, and make whatever changes to their orders that were necessary. If he was out of town, he'd hand them off to one of his partners, and return the favor when they were out of town. Now, that model is rare for a couple reasons. First, because primary care physicians are overworked, and don't relish the extra (often unpaid or severly underpaid) responsibility of caring for patients while they're hospitalized. Second, because primary care physicians are now being replaced with midlevel providers, like the nurse practitioner in this case. Unlike physicians, midlevels often either don't have admission privileges (in some states), or have admission priveledges that require that the patient be under the care of a physician after admission (in other states). The result is the creation of a relatively new specialty in medicine, the hospitalist, who is responsible for the care of admitted patients while there in the hospital. There's lots of evidence to show that this is generally a good thing for patient care, and definitely for quality of life for primary care providers. There's a physician on-duty 24/7/365 to care for hospitalized patients who specializes in care in that setting. But, as this case points out, it's not a system that's immune from flaws. There's also an imbalance of power and liability created by the introduction of a midlevel provider. While midlevel providers are an important and necessary part of providing primary care in our current medical system (though, in my personal opinion we should focus much more than we do on increasing our capacity for training physicians), their introduction does create a power and liability imbalance in our medical system. I expect that if the patient had been seen by an MD, who called the hospitalist and said "this patient is septic and needs to be admitted", the hospitalist would have been more likely to take their recommendation at face value. They would be getting a recommendation from a peer, with the same level of education and training as them, instead of a provider with less training and experience. Additionally, in cases like this, physicians carry an outsized responsibility for liability compared to midlevel providers. I don't bring any of this up to excuse the hospitalist invoved in this case. But it seems to me that this is a very clear case brought about by recent trends in the way we practice medicine in this country, that deserves further examination along those lines.
rgejman 7y ago
I haven't done a deep dive here... but this makes no sense for multiple reasons. 1. It will have a chilling effect on physicians giving informal ("curbside") consults to colleagues. That leads to worse patient care overall. For instance if your doctor doesn't know what's up with you, he/she may not be able to curbside consult phone a colleague to get a 2nd opinion. This happens all the time in medicine and is one of the advantages of being at a medical center with lots of doctors: you can double check weird cases with your colleagues. 2. Direct admission to the inpatient ward are no longer common because outside physicians don't run hospitals anymore. Hospitals are run by teams who specialize in inpatient medicine -- and they almost always function best if the inpatient admission is preceded by an ED visit because the ED can rapidly get tests, imaging and collateral to figure out what's wrong—and if the problem needs inpatient management or not. Direct admissions, in bypassing this step, often put patients at risk by skipping the rapid information gathering process that the ED employs. The "admitting privileges" they discuss in this article are a relatively meaningless and outdated practice in medicine today (with certain exceptions, such as obstetricians and some other surgeons).
- belorn 7y ago
  The case is limited to hospitals which only admit patients through doctor recommendations, and where the consultation is about admitting the patient to that specific hospital. If a doctor doesn't know what's up they can curbside consult phone a colleague to get a 2nd opinion. In my view, intention and context is what dictate most legal outcomes. That narrows decision usually down to very specific situations.
  - rgejman 7y ago
    Where does it say that? This NP was practicing independently and the Fairview hospital has an ED. There is no reason that if the NP was concerned she should not have sent the patient to the ED.
- PhasmaFelis 7y ago
  Asssuming the article is accurate, I think you're mis-characterizing what happened here. Simon wasn't calling a colleague for a second opinion before making a decision; she decided Warren needed to be admitted, called a senior hospitalist to expedite that admission, and was clearly and repeatedly refused. The OP's title "doctors can be sued by patients they don't treat" is not accurate. A better one might be "doctors can be sued by patients they refuse to allow treatment."
DanBC 7y ago
I'm amazed this need to go to supreme court because it seems obvious to me that you are responsible if you decline to admit someone based on a mini-dx you've made. > It raises at least three questions worthy of extensive public debate. The writer lists those 3 questions as > (1) Who authorized Fairview hospitalists to deny admission to patients they haven’t examined? > (2) Since when is diabetes a reasonable explanation of fever, chills and an elevated white-blood-cell count? > (3) What role did financial incentives and micromanagement of doctors play in inducing Drs. Dinter and Baldwin to make such a serious error? A more interesting question would be "does suing doctors prevent medical error or negligence?" The answer is probably no. Here's a rough guide of what should happen in England (although it often doesn't happen like this). https://improvement.nhs.uk/resources/just-culture-guide/ https://improvement.nhs.uk/resources/just-culture-guide/ That guide includes questions like "was there intent to cause harm?", "were there protocols in place?", "were those protocols followed?" > After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” [...] Rather than challenge Dinter’s flaky diagnosis, Simon asked him again to admit Warren. Dinter replied, “To what end?” (pp. 4-5) Simon got the message: Dinter had made up his mind he would not admit this patient, and he was not interested in further discussion. An important set of questions to ask are: 1) Could it be sepsis? 2) Why isn't it sepsis? 3) What things make it this other dx and not sepsis? There a bunch of information about how people perceived as lower status (nurses v doctors in this case) can challenge the other person in a way that causes a change in behaviour, rather than just a stubborn "digging the heels in response". Nurses play a crucial role in speaking up for patient safety. Probe: "I don't understand why ...?" Alert: "I am concerned that ..." Challenge: "This risks harm because ..." Emergency: "Stop. We need to get advice before we continue." Sadly, it looks like this nurse did try to challenge and was let down by other doctors.
- man2525 7y ago
  From the legal documents I skimmed, it looks like the state hospital association, state medical association, and american medical association were on the side of the defense. The SC chief justice and an associate justice dissented. I mentioned this to a friend who is a doctor, and he doesn't believe the AMA would take a position. Edit: Nevermind. The AMA's interest is that it is against abusive legislation against physicians. They felt the facts were recited more favorably to the prosecution.
duxup 7y ago
>After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” (as the Court of Appeals put it) and recommended that Simon send her home with some diabetes medication, and schedule a follow-up visit for next Monday, three days later. Upon hearing this strange diagnosis, Simon politely inquired whether it was accurate. “Simon says she asked whether diabetes could actually be the source of the elevated white-blood-cell count,” reported the court, “and that Dinter responded that it could. Simon says she asked this question because it was the first time someone had told her that out-of-control diabetes could cause a high white-cell count.” Rather than challenge Dinter’s flaky diagnosis, Simon asked him again to admit Warren. Dinter replied, “To what end?” (pp. 4-5) Simon got the message: Dinter had made up his mind he would not admit this patient, and he was not interested in further discussion. The hospitalist didn't treat the person directly, but they clearly made a decision about what to do with the patient.
yeahitslikethat 7y ago
Perhaps now we can start to allow patients to treat themselves? why should I need a doctor's permission to but insulin I know for a fact I need to live?
- ceejayoz 7y ago
  > Perhaps now we can start to allow patients to treat themselves? You already can. You're welcome to self-administer tylenol, bandage a wound, etc. When you start getting into more complicated conditions, we like to have a professional in the mix, as laypeople have a tendency to do things like want antibiotics for a cold, essential oils for cancer, and think vaccines cause autism.
  - yeahitslikethat 7y ago
    Insulin is not an antibiotic. You're straw manning. There are conditions patients have that, due to years with it, they know more about than the doctors and people should not be beholden to another by law to obtain the medicines they know they need to live. It's wrong. I need a doctor's permission to live. I'm forced to pay someone else to remain alive.
    - ceejayoz 7y ago
      They're examples of why "just let patients treat themselves" is frequently a horrible idea. A layperson shouldn't be diagnosing something like diabetes. Once you're on insulin, refills will typically be a (free!) phone call or email away. My daughter's on growth hormone, for example. Obtaining a new prescription when we run out of refills doesn't require payment or a visit. (The meds themselves do cost an insane amount, of course, and the doc does like to see her once in a while to make sure we've got the dosing right, which seems reasonable.)
      - yeahitslikethat 7y ago
        The individual should be sovereign over the self. You're fine needing permission to live. I'm not. I was clear about treating conditions the patients had for years. You straw manned again. You must have a conflict of interest. Maybe you are a doctor.
arkades 7y ago
So, without actually seeing the medical record, it's hard for any outsider to have a meaningful insight into this case. I'll make a few generalizations, though, based on what I can glean from the article: 1. "Admission to the hospital" means "being put in a bed upstairs to receive treatment that can only be given in a hospital over the course of days." For a hospitalist to admit, the patient bypasses the emergency room, bypasses an initial ED workup, and passes directly into that physician's care. I know don't know any hospitalists that will take a patient as described in this article for a direct admission. The patient either belongs in an outpatient management, or should be coming through the ED for initial speedy (relative to inpatient!) workup and therapy. Direct-to-inpatient admission is for hospital-only therapy that isn't an emergency - e.g., you need a week-long IV infusion of a medication. You'd get admitted directly to that physician's service, get brought in, get your infusion going, etc. Non-emergent. When a physician "refuses to admit" from outpatient clinic it does not mean "this patient can't come to the hospital". It means they don't avoid the ED and go straight to the slower inpatient care process. This patient may very well have needed some IV abx for six hours and then get sent home. That's not the hospitalist's call, and not what the hospitalist is described as doing in this article. Which makes sense, because /that's not how any of this works/. This article's suggestion that a hospitalist saying "I'm not admitting this patient" equals "this patient can't come to the hospital and should just go home" is inaccurate and sloppy reporting. It's just wrong. And you know what? The NP in this story knew that. "However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission." " The NP did the wrong thing, and the hospitalist saying No to the wrong thing is getting blamed. "If you have the power to decide on the treatment and hospital admission of a patient you have a patient-doctor relationship." is incorrect. This doctor did not have power to stop this patient from coming to the ED and getting ED care, which is the route the NP should have sent them through and the only route for getting emergency management in the hospital. The NP asked for a thing that does not happen and is not needed for the patient to get the right care and is in fact the Wrong care, and now it's being described as though the hospitalist had the power to say "go home or get hospital care." That's just incorrect. 2. Episodes of diabetic worsening can cause a white count, particularly if the patient is trending towards acidosis. The article calls this as "flaky diagnosis," and says "this is the first the NP heard of it," implying that this was untrue. It was not untrue. Though this certainly does sound like an infection, I imagine the actual conversation went "can I immediately admit this patient with this white count?" and the doc went, "this isn't that bad a white count, part of it is probably from the diabetes, also, no, I don't do admits from community, no." 3. NP's are supposed to practice under physician supervision. "Still concerned about Ms. Warren’s condition, Simon then spoke to Dr. Jan Baldwin, her “collaborating physician” at the Essentia clinic." So, she did an end-run around the normal admission process, and got bounced both for (a) possibly over-stating the white count?, and (b) ...because the route for this patient getting admitted is through the ED, not by calling not her supervising physician. She then went to her actual supervising physician, who apparently said the same thing about this patient. The article includes the line "but they didn't examine the patient." Yes, because they relied on the NP to furnish the physical exam details; they went to the EMR to check out all the lab values and vitals (because if they didn't, there'd be no public suit; the malpractice insurer would be running straight to a very nice settlement.) The very-neutral and well-researched article refers to this fact as "amazing." It's standard practice. (a) If you can't rely on an NP to convey the results of a physical exam, they shouldn't be allowed to have anything resembling independent practice rights. (b) you're legally allowed to rely on them to convey physical exam, and (c) there is no statement that anything in the physical exam is what changed the clinical picture here. So, two independent physicians looked at this patient's labs and didn't see an out-of-control infection - the only clinical counterpoint we're seeing is from an NP who apparently didn't know about the "every med student knows about this" fact that diabetes can drive a white count, and less controlled diabetes drives it more. I actually do think that there were a couple of fuck-ups here: (a) The NP should have sent the patient to the ED if they were convinced this patient was fucked up. Period. (b) The NP should not have called the hospitalist directly. Period. It's a red-herring to the entire event. The only question is "can I manage this outpatient or do I send them to the ED?" not "can I manage this outpatient or do I send them to inpatient where their work-up and treatment will be delayed 12-24 hours at a minimum, if inpatient would even take this patient bypassing the ED, which they won't, so why the fuck am I even calling them?" (c) Diabetic with a fever and a white count and out-of-control sugar can be poorly controlled diabetes. Or an incipient DKA. Or septic. Or having a heart attack. The supervising physician who directed outpatient management - not the hospitalist - made the probably-wrong call by sending this patient home. They should have directed to the patient to the ED. I can't say this more strongly without seeing the actual medical record, but if malpractice happened, it happened at this step. The "if" is because if the white count was only a little up, and the NP said, "well, they don't look septic," and the patient reports poor compliance with their diabetes meds, ... well, it would be reasonable to say, "eh, diabetes." I still would've sent to the ED, but this isn't my jam, so I could be wrong.
gonzoflip 7y ago
I was surprised to see the names in this story because I went to elementary school with Dr. Dinter's daughter. Hibbing is not a large town and I feel for everyone involved. This is a very sad story.
hedora 7y ago
This decision will hopefully have positive follow on effects for mental health care. Currently, (in California, so outside the jurisdiction of the court in the article), it is extremely difficult to get someone that is coherent, but violent or suicidal admitted to a hospital, even if they have insurance, doctors and family members that agree with hospitalization, etc. The next time someone like this is denied admission, and then commits suicide or murders a bunch of people at a school, religious / political gathering, etc, I hope the facility that denied admission is held financially responsible, and these policies are changed as a result.
- gamblor956 7y ago
  The next time someone like this is denied admission, and then commits suicide or murders a bunch of people at a school, religious / political gathering, etc, I hope the facility that denied admission is held financially responsible, and these policies are changed as a result. This doesn't make any sense... In California, the mentally ill can't be committed to a hospital against their wishes because they are deemed to have a constitutional right to be a stark, raving lunatic on public property. The hospital and family would have to show that the putative patient is a danger to themselves or others in order to get them committed to a hospital. However, if they have insurance, there wouldn't be any issue with a mental ill person being admitted to a hospital of their own will (or with the permission of someone designated to make medical decisions on their behalf aka medical power of attorney).
- JamesBarney 7y ago
  It's usually the courts based on expert testimony that gets people admitted into a hospital against their wishes.
ars 7y ago
Before making final judgment on how to think about this case, I suggest readers also read the comments in this article. They from Dr.'s with personal knowledge on the case, and it's not as simple as made out in the article.
beat 7y ago
"Will no one rid me of this meddlesome priest?" Plausible deniability for authority figures is and has always been a thing.
gumby 7y ago
HN headline is slightly misleading:* the doctors still made a treatment decision which is, as the courts sensibly held, is a medical decision (for example I would not be considered qualified to make such a decision). And while doctors are imperfect should not be punished for errors out of their reasonable control, this seems unambiguously to be malpractice. * the original title is useless so thanks to scripthacker for writing something more useful.
totaldude87 7y ago
Two parts to the story.. >However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission.” (p. 3) Simon’s call was routed to Dr. Richard Dinter, one of three hospitalists on call that day. --> Why call when you know something is off? After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” (as the Court of Appeals put it) and recommended that Simon send her home with some diabetes medication, and schedule a follow-up visit for next Monday, three days later --> Do this and get sued every time. The basic thing for a doctor to do is to check whats wrong with the patient and 9 out of 10 times, you need the patient in place to examine and declare..
equivocates 7y ago
Medical malpractice lawyer here: Setting aside the sensational headline, this seems a reasonable result. According to the article, the hospitalist who did not see the patient decided to (a) opine that her symptoms were due to some other, incorrect cause; and (b) override the decision of the doctor who actually saw the patient. Why shouldn't this individual have accountability for the harm that he caused? He wants to make life or death decisions without so much as examining the patient and he doesn't want to be held responsible for those decisions. How is that fair?
- jdoliner 7y ago
  Are there any similar prior cases where similar things have happened? Consults like this seem incredibly common, so it's hard to believe that this is the first one where the consult was wrong and it had consequences, maybe this is the first one where they thought to file a malpractice suit? It seems like this suit may have a chilling effect where Doctors won't even be willing to get on the phone for consults, given that they're taking on extra liability by doing so. Do you think that's a risk here?
  - aladoc99 7y ago
    Not a risk, a certainty. Until this ruling, not having a physician-patient relationship was an absolute safe harbor against professional liability. It was understood that the clinician seeing the patient had the ultimate responsibility. Now we can program Alexa to say "Send the patient to the ER" and save ourselves a great deal of time.
    - olliej 7y ago
      The ruling is that when you make a medical decision about a patient you have a physician/patient relationship. You no longer get to say “I was not present so that fact that I provided incorrect treatment instructions is irrelevant”. If the doctors involved weren’t the ones responsible for allowing a patient to be transferred to the hospital maybe you could more reasonably claim you were giving advice. But by denying the transfer to the hospital and misdiagnosing them, they were making (and effectively enforcing) those decisions.
tptacek 7y ago
The outcome here seems reasonable, but I'm a bit concerned about the jab at "value-based care" and "pay-for-performance" buried in the middle of it (in the "were there financial incentives in avoiding care" section). Americans are generally over-treated (ironically, one narrative for why this happens is a concern about malpractice suits). There's very good reason to shift compensation away from services rendered to outcomes achieved; there's also a long track record in the US of treatments, particular inpatient and outpatient "procedures", of dubious efficacy. The controversy over "useless" coronary stents is a good example, but a better one might be the difference in hernia treatment between the US (where the procedures tend to be outpatient laparoscopy) and the UK (inpatient, and performed with less frequency). The US pays substantially more than everyone else for medical care, and the reasons why probably don't have that much to do with prescription costs or administration, which make up a relatively small portion of total health spending; rather, we have inefficiently deployed hospitals, often with high vacancy rates, and prescribe a lot of procedures that might not need to occur. Obviously that's not what happened here!
ineedasername 7y ago
First, an important distinction: this decision did not actually find culpability or liability, it merely affirmed a right to sue. That aside, this seems a reasonable decision. A nurse practitioner advocated for hospital admission. They were overruled in the basis of medical analysis performed by an admiting doctor. The tenuous grounds for this denial are almost irrelevant in this decision (but certainly won't be in the lawsuit to come) because, even if it wasn't a formal doctor-patient relationship, the doctor rendered a medical judgement that had a direct impact of the care the patient received.
- Gibbon1 7y ago
  > The tenuous grounds for this denial are almost irrelevant in this decision Far as I understand dismissals are the result of the plaintiff having no case even if the 'facts' alleged are 'true'. So yeah the court isn't making any ruling at all on the malpractice allegations.
deleted 7y ago
[deleted]
tomohawk 7y ago
Hospitals have been known to ban certain people and refuse to treat them. This was not too much of a problem, but now that we have medicine 2.0, hospitals are now part of systems, and so a ban often extends to all hospitals in the system. For example Mayo clinic controls a large number of hospitals in a geographic area, so getting care if banned could be practically impossible. Here's an example of a dispute that led to a banning: https://www.mprnews.org/story/2018/08/15/mayo-disputes-medical-kidnapping-cnn-story https://www.mprnews.org/story/2018/08/15/mayo-disputes-medic... It's not clear what other remedy than a lawsuit would work in such a situation. Hopefully medicine 3.0 will be better.
xrd 7y ago
The nurse practitioner should have sent the patient to the ER. This result is reasonable. They made a serious mistake in sending the patient away.

123 points by scripthacker 7y ago

Makes total sense to me. If you have the power to decide on the treatment and hospital admission of a patient you have a patient-doctor relationship. If they want to reject responsibility they also should not have stated an opinion without seeing the patient.

amputect 7y ago
Yeah I came here to write more or less this exact comment -- the doctor absolutely did make a medical judgement on the patient, and frankly it was an astonishingly bad one. To declare, sight unseen, that a patient with several severe signs of infection is simply prediabetic, is negligent in the extreme, especially when the medical professional who is actually with the patient doesn't agree.
- amputect 7y ago
  Also I'd like to point out that the headline is, at best, highly misleading -- the doctor didn't see the patient, no, but that's the problem not an exculpatory factor. This isn't a random doctor being sued by a random patient it's a doctor whose medical judgement arguably led to the patient's death.
- maxxxxx 7y ago
  I am sure they dream of AI diagnosis. It can be optimized for profit and any negative effects can be blamed on the AI.
  - ska 7y ago
    It's more the other way around, at least in a US context. Concern of the impact of AI/physician disagreement is a problem from a malpractice point of view. Physicians in the US have a huge amount of professional leeway - hence the expansion of off-label use - but this is counterbalanced by a large amount of professional responsibility/liability.
- hn_throwaway_99 7y ago
  Moreover, the Dr's argument that he was just "giving an opinion", but did not actually accept or prevent her admittance, absolutely does not pass the smell test. He was in a position of power, and from the description of the phone call with the nurse practitioner in the article it is extremely clear he wasn't just "offering an opinion", but was in fact denying admittance. Honestly, I feel awful for the patient and her family, but I also feel awful for the NP who tried to do the right thing but was shot down by those with greater seniority than her. I hope her employer changes their training so that if something like this happens in the future that they just tell the patient to go directly to the ER.
  - Scoundreller 7y ago
    And to better assert the independence of NPs. At least with this lawsuit and settlement, NPs may be more legally motivated to do the right thing.
    - arkades 7y ago
      The NP in this story is one of the people that fucked up. A, because she should have sent them to the ED. B, because hospitalists have nothing to do with the ED, and she was trying to /bypass/ the ED. C, because she didn't need her supervising physician's permission to send the patient to the ED. D, just for kicks, diabetes absolutely causes a white count bump, especially during uncontrolled episodes, with the degree of one correlating to the other - something every med student is expected to know, and it's ridiculous that the NP didn't. "Legally motivated to do the right thing"? She's significantly more guilty than the hospitalist, who is a red-herring in this entire discussion ("I'm not the ED attending. Send her to the ED. The ED attending decides who gets admitted for non-elective admissions. Also, she might need urgent care, so she shouldn't wait the 12-24 hours hold-up that would occur if I admitted her directly." would have been the response of any hospitalist I've worked with) and yet he's vulnerable to a malpractice suit, and the NP is not. What legal motivation?
      - Scoundreller 7y ago
        I dunno how independently NPs can practise in MN. Sometimes they’re always under an MD and anything that happens is that MD’s responsibility. This can be relatively more true if they’re an employee vs. a contractor (at least where I live, dunno about MN). The NP settled their case out-of-court. So they were held liable, and we don’t know how much. The consulted MD felt like fighting it in court, and lost. That’s what makes this case a bit unusual because something bad happened and one person involved thought they weren’t accountable.
arkades 7y ago
I don't want to spam the thread by posting my comment all over it, so I'll ask you to read it downthread. The article highly mis-represents appropriate and routine procedure; the statement that the hospitalist here had the "power to decide on treatment and admission" is factually incorrect, though it's an incorrect impression the article very much tried to leave you with.
TazeTSchnitzel 7y ago
I don't know how it works in US law, but it reminded me exactly of the English tort law concept of “duty of care”, which can exist between two people even without direct contact.
jdoliner 7y ago
> they also should not have stated an opinion without seeing the patient. Doesn't that mean that the doctors choices basically boil down to 1) see every patient that you get a phone call about or 2) don't take phone calls? Given that I don't think 1 will scale very far it seems like most doctors will have to take option 2, I'm not sure if we're better off in a world where this type of consultation can't happen anymore for fear of liability.
- LoSboccacc 7y ago
  it's not either or, there's option 3 "I can't form an opinion over the phone, if your medic thinks this can't wait for standard admittance channels I kindly defer you to the emergency services." and likely others.
  - smackinglyt 7y ago
    Unfortunately, it's more complex than that. I'm a hospitalist at a pair of community hospitals that don't have some services (cardiology, vascular surgery, neurosurgery, ophtho, etc). I'm used to calling the specialist at our associated academic center when a possible acute problem related to those specialities may be happening. If those specialists now refuse to do "curbside" phone consults because they can't see the patient and now can get sued, these patients are in a bad position. The tertiery hospitals here are constantly full and I can't transfer patients that don't have immediate true emergencies. This opinion is a major loss for patients. And I also used to "decline" direct admissions based on phone consults, telling outpatient AP/NPs what I thought would be a reasonable course of action and follow-up. Will simply say "sorry" on the phone now and tell them to send the patient to the ED, where the costs are very high. This will simply jack up the cost for everyone else. Not saying the MD in the news article had a reasonable opinion. But spend a single day with me in our busy hospital, see just how tricky this profession is, and you might be convinced that I need more legal protection, not less.
    - scott00 7y ago
      In the event a primary care/urgent care doc disagrees with a hospitalist on the need for admission, why is sending them to the ED the right move? I was under the impression the ED is mostly for triage, and it seems like patients in this situation have already been triaged. It also seems like the sort of disagreement about the need for admission between urgent care and hospitalist is also going to happen sometimes between ED docs and hospitalists. How do those disputes get resolved?

Scoundreller 7y ago

I can’t figure out why the Nurse Practitioner didn’t send the patient to ER? Are direct admits to hospital that bypass ER common outside of, say, fractures or elective surgery?

maxxxxx 7y ago
I bet it's because they system is very hierarchical. Once a doctor says something the nurse can't really override it.
- teej 7y ago
  The hospitalist is acting as the “gatekeeper” to admission here, so they decide if the hospital will take the patient or not. That doesn’t stop the NP from shipping the patient straight to the hospital’s ER. By federal law, emergency rooms must see every patient who comes in their doors.
- rustybelt 7y ago
  The NP absolutely could have sent the patient to the ER. The vast majority of patients admitted to a hospital come in through the ER.
  - maxxxxx 7y ago
    From what I know about hospitals the NP is supposed to defer to the doctors.
    - Scoundreller 7y ago
      I think there’s big variation state-by-state in terms of NP independence.
  - SolarNet 7y ago
    I think the problem is she brought it to her organization's doctor that often does the ER admitting in situations like this and that doctor overruled her. The NP could still have done it, but it would have been against two different doctors and the organization who employs her practices. The sad thing is that this probably happens often, this is just the first time someone sued over the death.

toomuchtodo 7y ago

Mods: Original title of piece is "Why Did Susan Warren Die?". Can we get it updated to be less sensational? TLDR: A “curbside consult" establishes a physician-patient relationship. EDIT: Mods have spoken. Can't delete due to replies, feel free to ignore.

teej 7y ago
The judgement specifically states that this is more than a curbside consult.
SiempreViernes 7y ago
I feel the story told by article deserves a fairly sensational title! I do agree that the current title is sensationalizing the wrong aspect though, something like "Minnesota doctors routinely ignore diagnosed treatment" would more apt.
- toomuchtodo 7y ago
  I agree.
brlewis 7y ago
Mods asked a question, not rendering final judgement: https://news.ycombinator.com/item?id=20205224 https://news.ycombinator.com/item?id=20205224 I'd still like to see a less sensational headline and replied there.

edaemon 7y ago

For what it's worth, the submission title ("Minnesota court decision means doctors can be sued by patients they don't see") does not match the article's title, nor does it really match its argument. From the article: >The court concluded that Justin Warren did not have to prove that his mother was in a doctor-patient relationship with Dinter in order to proceed to trial. This was unquestionably the correct decision.

dang 7y ago
The article title is baity, so the submitter correctly changed it in accordance with the site guidelines: https://news.ycombinator.com/newsguidelines.html https://news.ycombinator.com/newsguidelines.html. I'm not clear on how the title doesn't match the article? It's consistent with language in the opening paragraph. I changed "see" to "treat", though, since that's more specific.
- SiempreViernes 7y ago
  The main message of the article is more about how doctors routinely deny admission of patients to their hospitals without actually seeing them, and how this is a very strange practice that in this case might have lead to an avoidable death (and certainly to a more agonizing end as no palliative treatment was possible). The title speaks only of the fairly common sense ruling that actively denying admission constitutes a clinical decision
- edaemon 7y ago
  I don't think the title here needs to be changed significantly, I was just pointing out that it implies something different from the article contents. The title paints the court's decision as if it's about treatment while the decision is actually about assessment. Going by the title one could think anyone could sue a doctor despite never interacting with them, while the article explains that this decision allows you to sue if you are actively refused treatment based on a doctor's assessment (the implication being that the doctor was wrong when they refused to admit/treat you). Perhaps a better title would be something like "Minnesota court decision means doctors can be sued by patients they refuse to treat".

Glyptodon 7y ago

I think the submitted headline is misleading. It's more accurate to say "doctors can be held accountable for medical decisions they make without even seeing a patient."

Gibbon1 7y ago
It's misleading because the doctor did look at the blood test results and the patients history and then made a decision to refuse appropriate care. What I think contrary to what a lot of doctors believe[1] the license comes with a large amount of duty. [1] And definitely what the suits that run hospital chains believe.

jawns 7y ago

I think it really hinges on whether this is a "curbside consult" or an actual denial of service. Based on the facts details in the post, it is at least arguable that the conversation between the NP and the doctor was merely a consultation on a diagnosis, which medical professionals do among themselves all the time, and not an actual denial of service. Simon, the NP, described the symptoms to Dinter, the MD, and he gave his opinion -- which turned out to be a really bad opinion with deadly consequences. But I think it could be argued that it is ultimately the responsibility of the NP or doc who is actually treating the patient, not any physician she might have consulted (and especially not one who has not actually seen the patient), to recognize when she's being given horrible advice. And it seems as if she did recognize that it was horrible advice, but wasn't willing to overrule it and send the patient to the ER against Dinter's advice. The post says that Dinter implied, during his conversation with Simon, that it would be pointless to admit the patient. But does that mean he _refused_ to admit her? It seems to me that there's at least arguably a difference between the two, and that his conduct did not actually constitute a refusal of service.

SiempreViernes 7y ago
> Dinter also implied that it would be pointless to admit the patient. But does that mean he _refused_ to admit her? He said it in the context of someone explicitly asking him to admit a patient, of course it's a refusal! The most commons way to refuse to answer questions likewise doesn't explicitly involve shouting "I refuse" loudly.
- jawns 7y ago
  Let's agree that a reasonable person would see that as a refusal. In fact, let's make the refusal even more explicit. Let's suppose that he flat-out said, "I don't think she needs emergency care, and if you send this patient to the ER, I will refuse to treat her." Even so ... isn't it ultimately on the NP -- who seemed to grasp that he was blowing her off -- to either get a second opinion or (ideally) use her own medical training to determine that the patient really should go to the ER, no matter what he says, knowing that he can't actually refuse to treat her? Stating that you intend not to do something, after all, is not always the same as actually refusing to do it. That's not the most compelling argument, I know. But I do worry about the broader implications of this ruling. Should physicians fear malpractice claims arising out of consultations with colleagues? In what cases can you feel free to give your opinion "off the record," with the understanding that the person who has consulted you will bear ultimate responsibility for the treatment they are providing?

atourgates 7y ago

The other (IMO very critical) factors this doesn't address is the relationship between midlevel providers and MDs, and the shift towards away from primary-care providers and specialists treating their patients during hospitalization to hospitalists treating patients during hospitalization. 30 years ago, the patient likely would have seen their family doctor, who would have caught the symptoms of sepsis (just like the midlevel nurse practitioner did), and then directly admitted the patient into the hospital themselves, and cared for the patient during their admission. I grew up with a father who was a primary care physician in a rural community. If one of his patients required admission to the local hospital, he'd admit them directly. It was normal that on Saturday and Sunday mornings, then-6-year-old-me would tag along as he rounded through his patients in the hospital. He'd manage their care, talk with them about their symptoms and progress, and make whatever changes to their orders that were necessary. If he was out of town, he'd hand them off to one of his partners, and return the favor when they were out of town. Now, that model is rare for a couple reasons. First, because primary care physicians are overworked, and don't relish the extra (often unpaid or severly underpaid) responsibility of caring for patients while they're hospitalized. Second, because primary care physicians are now being replaced with midlevel providers, like the nurse practitioner in this case. Unlike physicians, midlevels often either don't have admission privileges (in some states), or have admission priveledges that require that the patient be under the care of a physician after admission (in other states). The result is the creation of a relatively new specialty in medicine, the hospitalist, who is responsible for the care of admitted patients while there in the hospital. There's lots of evidence to show that this is generally a good thing for patient care, and definitely for quality of life for primary care providers. There's a physician on-duty 24/7/365 to care for hospitalized patients who specializes in care in that setting. But, as this case points out, it's not a system that's immune from flaws. There's also an imbalance of power and liability created by the introduction of a midlevel provider. While midlevel providers are an important and necessary part of providing primary care in our current medical system (though, in my personal opinion we should focus much more than we do on increasing our capacity for training physicians), their introduction does create a power and liability imbalance in our medical system. I expect that if the patient had been seen by an MD, who called the hospitalist and said "this patient is septic and needs to be admitted", the hospitalist would have been more likely to take their recommendation at face value. They would be getting a recommendation from a peer, with the same level of education and training as them, instead of a provider with less training and experience. Additionally, in cases like this, physicians carry an outsized responsibility for liability compared to midlevel providers. I don't bring any of this up to excuse the hospitalist invoved in this case. But it seems to me that this is a very clear case brought about by recent trends in the way we practice medicine in this country, that deserves further examination along those lines.

rgejman 7y ago

I haven't done a deep dive here... but this makes no sense for multiple reasons. 1. It will have a chilling effect on physicians giving informal ("curbside") consults to colleagues. That leads to worse patient care overall. For instance if your doctor doesn't know what's up with you, he/she may not be able to curbside consult phone a colleague to get a 2nd opinion. This happens all the time in medicine and is one of the advantages of being at a medical center with lots of doctors: you can double check weird cases with your colleagues. 2. Direct admission to the inpatient ward are no longer common because outside physicians don't run hospitals anymore. Hospitals are run by teams who specialize in inpatient medicine -- and they almost always function best if the inpatient admission is preceded by an ED visit because the ED can rapidly get tests, imaging and collateral to figure out what's wrong—and if the problem needs inpatient management or not. Direct admissions, in bypassing this step, often put patients at risk by skipping the rapid information gathering process that the ED employs. The "admitting privileges" they discuss in this article are a relatively meaningless and outdated practice in medicine today (with certain exceptions, such as obstetricians and some other surgeons).

belorn 7y ago
The case is limited to hospitals which only admit patients through doctor recommendations, and where the consultation is about admitting the patient to that specific hospital. If a doctor doesn't know what's up they can curbside consult phone a colleague to get a 2nd opinion. In my view, intention and context is what dictate most legal outcomes. That narrows decision usually down to very specific situations.
- rgejman 7y ago
  Where does it say that? This NP was practicing independently and the Fairview hospital has an ED. There is no reason that if the NP was concerned she should not have sent the patient to the ED.
PhasmaFelis 7y ago
Asssuming the article is accurate, I think you're mis-characterizing what happened here. Simon wasn't calling a colleague for a second opinion before making a decision; she decided Warren needed to be admitted, called a senior hospitalist to expedite that admission, and was clearly and repeatedly refused. The OP's title "doctors can be sued by patients they don't treat" is not accurate. A better one might be "doctors can be sued by patients they refuse to allow treatment."

DanBC 7y ago

I'm amazed this need to go to supreme court because it seems obvious to me that you are responsible if you decline to admit someone based on a mini-dx you've made. > It raises at least three questions worthy of extensive public debate. The writer lists those 3 questions as > (1) Who authorized Fairview hospitalists to deny admission to patients they haven’t examined? > (2) Since when is diabetes a reasonable explanation of fever, chills and an elevated white-blood-cell count? > (3) What role did financial incentives and micromanagement of doctors play in inducing Drs. Dinter and Baldwin to make such a serious error? A more interesting question would be "does suing doctors prevent medical error or negligence?" The answer is probably no. Here's a rough guide of what should happen in England (although it often doesn't happen like this). https://improvement.nhs.uk/resources/just-culture-guide/ https://improvement.nhs.uk/resources/just-culture-guide/ That guide includes questions like "was there intent to cause harm?", "were there protocols in place?", "were those protocols followed?" > After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” [...] Rather than challenge Dinter’s flaky diagnosis, Simon asked him again to admit Warren. Dinter replied, “To what end?” (pp. 4-5) Simon got the message: Dinter had made up his mind he would not admit this patient, and he was not interested in further discussion. An important set of questions to ask are: 1) Could it be sepsis? 2) Why isn't it sepsis? 3) What things make it this other dx and not sepsis? There a bunch of information about how people perceived as lower status (nurses v doctors in this case) can challenge the other person in a way that causes a change in behaviour, rather than just a stubborn "digging the heels in response". Nurses play a crucial role in speaking up for patient safety. Probe: "I don't understand why ...?" Alert: "I am concerned that ..." Challenge: "This risks harm because ..." Emergency: "Stop. We need to get advice before we continue." Sadly, it looks like this nurse did try to challenge and was let down by other doctors.

man2525 7y ago
From the legal documents I skimmed, it looks like the state hospital association, state medical association, and american medical association were on the side of the defense. The SC chief justice and an associate justice dissented. I mentioned this to a friend who is a doctor, and he doesn't believe the AMA would take a position. Edit: Nevermind. The AMA's interest is that it is against abusive legislation against physicians. They felt the facts were recited more favorably to the prosecution.

duxup 7y ago

>After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” (as the Court of Appeals put it) and recommended that Simon send her home with some diabetes medication, and schedule a follow-up visit for next Monday, three days later. Upon hearing this strange diagnosis, Simon politely inquired whether it was accurate. “Simon says she asked whether diabetes could actually be the source of the elevated white-blood-cell count,” reported the court, “and that Dinter responded that it could. Simon says she asked this question because it was the first time someone had told her that out-of-control diabetes could cause a high white-cell count.” Rather than challenge Dinter’s flaky diagnosis, Simon asked him again to admit Warren. Dinter replied, “To what end?” (pp. 4-5) Simon got the message: Dinter had made up his mind he would not admit this patient, and he was not interested in further discussion. The hospitalist didn't treat the person directly, but they clearly made a decision about what to do with the patient.

yeahitslikethat 7y ago

Perhaps now we can start to allow patients to treat themselves? why should I need a doctor's permission to but insulin I know for a fact I need to live?

ceejayoz 7y ago
> Perhaps now we can start to allow patients to treat themselves? You already can. You're welcome to self-administer tylenol, bandage a wound, etc. When you start getting into more complicated conditions, we like to have a professional in the mix, as laypeople have a tendency to do things like want antibiotics for a cold, essential oils for cancer, and think vaccines cause autism.
- yeahitslikethat 7y ago
  Insulin is not an antibiotic. You're straw manning. There are conditions patients have that, due to years with it, they know more about than the doctors and people should not be beholden to another by law to obtain the medicines they know they need to live. It's wrong. I need a doctor's permission to live. I'm forced to pay someone else to remain alive.
  - ceejayoz 7y ago
    They're examples of why "just let patients treat themselves" is frequently a horrible idea. A layperson shouldn't be diagnosing something like diabetes. Once you're on insulin, refills will typically be a (free!) phone call or email away. My daughter's on growth hormone, for example. Obtaining a new prescription when we run out of refills doesn't require payment or a visit. (The meds themselves do cost an insane amount, of course, and the doc does like to see her once in a while to make sure we've got the dosing right, which seems reasonable.)
    - yeahitslikethat 7y ago
      The individual should be sovereign over the self. You're fine needing permission to live. I'm not. I was clear about treating conditions the patients had for years. You straw manned again. You must have a conflict of interest. Maybe you are a doctor.

arkades 7y ago

So, without actually seeing the medical record, it's hard for any outsider to have a meaningful insight into this case. I'll make a few generalizations, though, based on what I can glean from the article: 1. "Admission to the hospital" means "being put in a bed upstairs to receive treatment that can only be given in a hospital over the course of days." For a hospitalist to admit, the patient bypasses the emergency room, bypasses an initial ED workup, and passes directly into that physician's care. I know don't know any hospitalists that will take a patient as described in this article for a direct admission. The patient either belongs in an outpatient management, or should be coming through the ED for initial speedy (relative to inpatient!) workup and therapy. Direct-to-inpatient admission is for hospital-only therapy that isn't an emergency - e.g., you need a week-long IV infusion of a medication. You'd get admitted directly to that physician's service, get brought in, get your infusion going, etc. Non-emergent. When a physician "refuses to admit" from outpatient clinic it does not mean "this patient can't come to the hospital". It means they don't avoid the ED and go straight to the slower inpatient care process. This patient may very well have needed some IV abx for six hours and then get sent home. That's not the hospitalist's call, and not what the hospitalist is described as doing in this article. Which makes sense, because /that's not how any of this works/. This article's suggestion that a hospitalist saying "I'm not admitting this patient" equals "this patient can't come to the hospital and should just go home" is inaccurate and sloppy reporting. It's just wrong. And you know what? The NP in this story knew that. "However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission." " The NP did the wrong thing, and the hospitalist saying No to the wrong thing is getting blamed. "If you have the power to decide on the treatment and hospital admission of a patient you have a patient-doctor relationship." is incorrect. This doctor did not have power to stop this patient from coming to the ED and getting ED care, which is the route the NP should have sent them through and the only route for getting emergency management in the hospital. The NP asked for a thing that does not happen and is not needed for the patient to get the right care and is in fact the Wrong care, and now it's being described as though the hospitalist had the power to say "go home or get hospital care." That's just incorrect. 2. Episodes of diabetic worsening can cause a white count, particularly if the patient is trending towards acidosis. The article calls this as "flaky diagnosis," and says "this is the first the NP heard of it," implying that this was untrue. It was not untrue. Though this certainly does sound like an infection, I imagine the actual conversation went "can I immediately admit this patient with this white count?" and the doc went, "this isn't that bad a white count, part of it is probably from the diabetes, also, no, I don't do admits from community, no." 3. NP's are supposed to practice under physician supervision. "Still concerned about Ms. Warren’s condition, Simon then spoke to Dr. Jan Baldwin, her “collaborating physician” at the Essentia clinic." So, she did an end-run around the normal admission process, and got bounced both for (a) possibly over-stating the white count?, and (b) ...because the route for this patient getting admitted is through the ED, not by calling not her supervising physician. She then went to her actual supervising physician, who apparently said the same thing about this patient. The article includes the line "but they didn't examine the patient." Yes, because they relied on the NP to furnish the physical exam details; they went to the EMR to check out all the lab values and vitals (because if they didn't, there'd be no public suit; the malpractice insurer would be running straight to a very nice settlement.) The very-neutral and well-researched article refers to this fact as "amazing." It's standard practice. (a) If you can't rely on an NP to convey the results of a physical exam, they shouldn't be allowed to have anything resembling independent practice rights. (b) you're legally allowed to rely on them to convey physical exam, and (c) there is no statement that anything in the physical exam is what changed the clinical picture here. So, two independent physicians looked at this patient's labs and didn't see an out-of-control infection - the only clinical counterpoint we're seeing is from an NP who apparently didn't know about the "every med student knows about this" fact that diabetes can drive a white count, and less controlled diabetes drives it more. I actually do think that there were a couple of fuck-ups here: (a) The NP should have sent the patient to the ED if they were convinced this patient was fucked up. Period. (b) The NP should not have called the hospitalist directly. Period. It's a red-herring to the entire event. The only question is "can I manage this outpatient or do I send them to the ED?" not "can I manage this outpatient or do I send them to inpatient where their work-up and treatment will be delayed 12-24 hours at a minimum, if inpatient would even take this patient bypassing the ED, which they won't, so why the fuck am I even calling them?" (c) Diabetic with a fever and a white count and out-of-control sugar can be poorly controlled diabetes. Or an incipient DKA. Or septic. Or having a heart attack. The supervising physician who directed outpatient management - not the hospitalist - made the probably-wrong call by sending this patient home. They should have directed to the patient to the ED. I can't say this more strongly without seeing the actual medical record, but if malpractice happened, it happened at this step. The "if" is because if the white count was only a little up, and the NP said, "well, they don't look septic," and the patient reports poor compliance with their diabetes meds, ... well, it would be reasonable to say, "eh, diabetes." I still would've sent to the ED, but this isn't my jam, so I could be wrong.

gonzoflip 7y ago

I was surprised to see the names in this story because I went to elementary school with Dr. Dinter's daughter. Hibbing is not a large town and I feel for everyone involved. This is a very sad story.

hedora 7y ago

This decision will hopefully have positive follow on effects for mental health care. Currently, (in California, so outside the jurisdiction of the court in the article), it is extremely difficult to get someone that is coherent, but violent or suicidal admitted to a hospital, even if they have insurance, doctors and family members that agree with hospitalization, etc. The next time someone like this is denied admission, and then commits suicide or murders a bunch of people at a school, religious / political gathering, etc, I hope the facility that denied admission is held financially responsible, and these policies are changed as a result.

gamblor956 7y ago
The next time someone like this is denied admission, and then commits suicide or murders a bunch of people at a school, religious / political gathering, etc, I hope the facility that denied admission is held financially responsible, and these policies are changed as a result. This doesn't make any sense... In California, the mentally ill can't be committed to a hospital against their wishes because they are deemed to have a constitutional right to be a stark, raving lunatic on public property. The hospital and family would have to show that the putative patient is a danger to themselves or others in order to get them committed to a hospital. However, if they have insurance, there wouldn't be any issue with a mental ill person being admitted to a hospital of their own will (or with the permission of someone designated to make medical decisions on their behalf aka medical power of attorney).
JamesBarney 7y ago
It's usually the courts based on expert testimony that gets people admitted into a hospital against their wishes.

ars 7y ago

Before making final judgment on how to think about this case, I suggest readers also read the comments in this article. They from Dr.'s with personal knowledge on the case, and it's not as simple as made out in the article.

beat 7y ago

"Will no one rid me of this meddlesome priest?" Plausible deniability for authority figures is and has always been a thing.

gumby 7y ago

HN headline is slightly misleading:* the doctors still made a treatment decision which is, as the courts sensibly held, is a medical decision (for example I would not be considered qualified to make such a decision). And while doctors are imperfect should not be punished for errors out of their reasonable control, this seems unambiguously to be malpractice. * the original title is useless so thanks to scripthacker for writing something more useful.

totaldude87 7y ago

Two parts to the story.. >However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission.” (p. 3) Simon’s call was routed to Dr. Richard Dinter, one of three hospitalists on call that day. --> Why call when you know something is off? After hearing Simon’s summary of Warren’s symptoms, Dr. Dinter declared her symptoms were due to “a diabetes that’s out of control” (as the Court of Appeals put it) and recommended that Simon send her home with some diabetes medication, and schedule a follow-up visit for next Monday, three days later --> Do this and get sued every time. The basic thing for a doctor to do is to check whats wrong with the patient and 9 out of 10 times, you need the patient in place to examine and declare..

equivocates 7y ago

Medical malpractice lawyer here: Setting aside the sensational headline, this seems a reasonable result. According to the article, the hospitalist who did not see the patient decided to (a) opine that her symptoms were due to some other, incorrect cause; and (b) override the decision of the doctor who actually saw the patient. Why shouldn't this individual have accountability for the harm that he caused? He wants to make life or death decisions without so much as examining the patient and he doesn't want to be held responsible for those decisions. How is that fair?

jdoliner 7y ago
Are there any similar prior cases where similar things have happened? Consults like this seem incredibly common, so it's hard to believe that this is the first one where the consult was wrong and it had consequences, maybe this is the first one where they thought to file a malpractice suit? It seems like this suit may have a chilling effect where Doctors won't even be willing to get on the phone for consults, given that they're taking on extra liability by doing so. Do you think that's a risk here?
- aladoc99 7y ago
  Not a risk, a certainty. Until this ruling, not having a physician-patient relationship was an absolute safe harbor against professional liability. It was understood that the clinician seeing the patient had the ultimate responsibility. Now we can program Alexa to say "Send the patient to the ER" and save ourselves a great deal of time.
  - olliej 7y ago
    The ruling is that when you make a medical decision about a patient you have a physician/patient relationship. You no longer get to say “I was not present so that fact that I provided incorrect treatment instructions is irrelevant”. If the doctors involved weren’t the ones responsible for allowing a patient to be transferred to the hospital maybe you could more reasonably claim you were giving advice. But by denying the transfer to the hospital and misdiagnosing them, they were making (and effectively enforcing) those decisions.

tptacek 7y ago

The outcome here seems reasonable, but I'm a bit concerned about the jab at "value-based care" and "pay-for-performance" buried in the middle of it (in the "were there financial incentives in avoiding care" section). Americans are generally over-treated (ironically, one narrative for why this happens is a concern about malpractice suits). There's very good reason to shift compensation away from services rendered to outcomes achieved; there's also a long track record in the US of treatments, particular inpatient and outpatient "procedures", of dubious efficacy. The controversy over "useless" coronary stents is a good example, but a better one might be the difference in hernia treatment between the US (where the procedures tend to be outpatient laparoscopy) and the UK (inpatient, and performed with less frequency). The US pays substantially more than everyone else for medical care, and the reasons why probably don't have that much to do with prescription costs or administration, which make up a relatively small portion of total health spending; rather, we have inefficiently deployed hospitals, often with high vacancy rates, and prescribe a lot of procedures that might not need to occur. Obviously that's not what happened here!

ineedasername 7y ago

First, an important distinction: this decision did not actually find culpability or liability, it merely affirmed a right to sue. That aside, this seems a reasonable decision. A nurse practitioner advocated for hospital admission. They were overruled in the basis of medical analysis performed by an admiting doctor. The tenuous grounds for this denial are almost irrelevant in this decision (but certainly won't be in the lawsuit to come) because, even if it wasn't a formal doctor-patient relationship, the doctor rendered a medical judgement that had a direct impact of the care the patient received.

Gibbon1 7y ago
> The tenuous grounds for this denial are almost irrelevant in this decision Far as I understand dismissals are the result of the plaintiff having no case even if the 'facts' alleged are 'true'. So yeah the court isn't making any ruling at all on the malpractice allegations.

deleted 7y ago

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tomohawk 7y ago

Hospitals have been known to ban certain people and refuse to treat them. This was not too much of a problem, but now that we have medicine 2.0, hospitals are now part of systems, and so a ban often extends to all hospitals in the system. For example Mayo clinic controls a large number of hospitals in a geographic area, so getting care if banned could be practically impossible. Here's an example of a dispute that led to a banning: https://www.mprnews.org/story/2018/08/15/mayo-disputes-medical-kidnapping-cnn-story https://www.mprnews.org/story/2018/08/15/mayo-disputes-medic... It's not clear what other remedy than a lawsuit would work in such a situation. Hopefully medicine 3.0 will be better.

xrd 7y ago

The nurse practitioner should have sent the patient to the ER. This result is reasonable. They made a serious mistake in sending the patient away.