Risk Management

Practice Pitfalls of the Consulting Physician

By John W. Shore, MD, FACS

Dr. Shore is a member of OMIC’s Risk Management and Underwriting Committees and an oculoplastic subspecialist in Austin, TX.

Digest, Summer, 2002

Most ophthalmologists spend the majority of their time treating and caring for patients and delivering direct patient care on a daily basis. Some ophthalmologists, however, have pure consulting practices in which the majority of their professional time is spent evaluating patients referred for consultation. Regardless of the type of practice, most ophthalmologists move in and out of the role of consulting physician on a regular basis. It is in this capacity that ophthalmologists must be vigilant and maintain an awareness of the “practice pitfalls” of consulting that may have medical-legal consequences.

Failure to communicate is probably the most single most important impediment to good patient care when treating and consulting physicians interact. Problems can develop quickly, when least expected, and may lead to adverse outcomes or medical-legal nightmares. Often the error is one of omission. The unwary consulting physician fails to define his or her roles as a consultant; does not follow through and complete the consultation; does not follow up to ensure that everyone involved “got the message” that specific, recommended intervention was considered or carried out; or is lax in communicating his or her recommendations to the physician(s) who requested the consultation.

To avoid problems, the consulting physician should anticipate potential adverse outcomes; communicate specific recommendations to the referring physician, the patient, and family; and document the key elements of future care and his or her role in that care. Let us consider three hypothetical cases in which the consulting ophthalmologist took the necessary precautions to ensure the best possible outcome for the patient and a defensible level of care in the event that the patient or family later filed a malpractice claim.

Define Your Role in the Overall Care of the Patient

Two very concerned parents bring their two-year-old child to your office for evaluation and fitting of an ocular prosthesis. The child has recently undergone enucleation at a major medical center for treatment of sporadic, unilateral retinoblastoma. The parents do not have an medical records in their possession, and there is no referral letter or telephone contact from the university where the child had surgery. The parents relate that they were instructed to see you to arrange for the fitting of an artificial eye.

One can envision several unpleasant scenarios whereby you could potentially become ensnarled in a messy case of alleged mismanaged cancer unless you take important steps to define what responsibility you will assume for the continued care of the patient going forward. On the one hand, you can perform the socket evaluation and refer the child to an ocularist for fabrication and fitting of the prosthesis. Periodic visits will allow you to manage the typical problems that invariably occur in patients with an anophthalmic socket and to ensure there was a good fit. Alternatively, you can assume total responsibility for the ongoing ophthalmologic care of the patient (assuming the parents agree), including the ongoing observation and treatment of the unoperated eye and screening for metastasis (a role most ophthalmologist would not want to take on at this stage).

To avoid problems, you must define your role (limited or comprehensive) and make sure all involved in the child’s care understand what you will and will not contribute to the overall management of the patient. In this scenario, communicate verbally and by means of a letter to the parents the limited role you are assuming in the overall care of their child. Spell out in very clear and certain terms that you are the consultant for the pediatrician and will watch the operated anophthalmic socket and provide limited vision care for the unoperated eye. Clearly state that responsibility for cancer management rests with the university physician(s). While you may be willing to coordinate local and distant care, indicate that you will not assume responsibility for treating the remaining eye. You also may want to emphasize that you will not be providing periodic metastatic screening. You should note in the medical record that you have had this conversation and that the parents have acknowledged and agreed to the arrangement.

During each office visit, ask the parents about the university visits and document that you have done so. Periodic letters that update others caring for the child will establish that you are fulfilling your limited role in the overall care of the child. A documented phone call to the university physician(s) also may be appropriate.

Transition from Consulting to Treating Physician

You are on call for you group practice. On Saturday afternoon, the employed optometrist of an ophthalmologist who lives in a rural area calls you to ask for advice. The MD and OD practice together and provide regional eye care for a two-county rural area. They are the only eye care specialists in that geographic region located 100 miles from you. As a corneal surgeon, you benefit from referrals of complicated anterior segment cases in their practice. The ophthalmologist is away on a seven-day vacation and the optometrist is taking his calls.

The OD calls you to inquire about a 36-hour postop patient whom he is seeing at his office with what appears to be some inflammation manifest by pain, a mild AC reactions, normal IOP, and a pinhole vision at the level of 20/30. The referring optometrist does not see any vitritis. You know the optometrist and trust him, but you are uncomfortable because he does not have any details of the surgery and you cannot readily judge the severity of the ocular findings based on your discussion with him. You decide you must see the patient and recommend that patient come in your office immediately. Transportation is a problem for the family and it is late in the afternoon. The optometrist offers to check the patient in the morning and call you if things look worse.

Fortunately, you do not agree. You explain your concern regarding the possibility of endophthalmitis and unequivocally let everyone know that if you are going to remain involved in this case, you must see the patient in your office as soon as possible. The family balks but relents when you warn them of the potential medical consequences of inaction. You give the family explicit directions to your office and set a time to meet them. You give them your beeper number, cell phone number, and home telephone number. You instruct them to call you if they have any problems finding your office. If endophthalmitis is present and poor visual outcome results, you as the consulting ophthalmologist are probably in as good a medical-legal position as possible. You handled the handoff well and the documentation is in your medical record.

There are two important medical-legal points to consider in this case. First, you can’t always control how you get involved in a case, but from the point of entry, you should do all you can to take charge and actively manage the problem. Second, when making the transition from consulting to treating physician in high risk cases, you must establish the parameters for the transfer of the patient’s care, including the time, place, and circumstances for the first visit and instructions for intervening care, if any. Give the patient, family, and referring health care provider clear direction on how and when you expect the transfer of care to take place in order for you to remain involved in the case. The goal is to establish a seamless transfer of care by communicating specific instructions to all involved. Always document your instructions, citing times, circumstances, and relevant conversations and the failure, if any, of the patient or others to follow your directions. This is the only means you have to decrease your liability should there be an adverse outcome. Your diligence will assure a wholesome, vigorous and, hopefully, successful defense if litigation ensues.

Follow Through and Complete the Consult

You are an oculoplastic subspecialist. You are not on call, but you are awakened in the middle of the night by a colleague’s phone call from the local emergency room. The caller is a retinal specialist. She is treating a 35-year-old man who suffered a penetrating orbital injury with a pellet shot from a pistol. The site is at the eyelid crease in the central upper eyelid. There is the possibility of an ocular injury. The retinal surgeon is going to explore the globe and suture the eyelid. A CT scan reveals the missile is lodged in the orbital apex just lateral to the optic nerve, which has not been severed. There is no evidence of bony penetration outside the orbit. The patient is lucid and otherwise stable. The question posed to you is, “Do I need to do anything about the pellet in the apex of the orbit?” You offer to come in and examine the patient, but the retina specialist declines, stating it is not necessary as it is very late and she thinks she can handle it. She will call you in the morning after she sees how things go. You opine that, in most cases, pellets lodged in the orbital apex do not need to be removed. The next day you hear nothing further. You are uneasy but not sure if you are “on” or “off” the case and don’t want to intrude as it is not your patient.

It is important to realize in this case that you may have unknowingly assumed a great deal of the responsibility for the care of this patient even though you have never examined or treated him. You were called by another surgeon because you have specific knowledge and expertise in orbital disease. You rendered an opinion and recommended nonintervention (which was entirely appropriate). She relied on your recommendations to formulate her plan of care and took (or did not take) specific action based on your advice. Now she is focused on the management of the ocular aspects of the case.

Who is responsible for the management of the oculoplastic aspects of the case? Some courts may hold that you have established a physician-patient relationship and bear a duty to the patient to meet the standard of care of an oculoplastic subspecialist in the continued management of this patient. The retinal surgeon would be expected to recognize the potential for levator injury; however, it is unlikely that she has the experience, skill, or training necessary to treat the oculoplastic elements of the combined injuries appropriately. If you fail to follow up on the consult and bring your experience and training to bear, you could potentially find yourself legally liable for any adverse outcome. While the retina specialist could be found negligent for failing to insist that you follow up on the case, you still might not be absolved of your responsibility just because she did not call you a second time. Since you were consulted by telephone, you may be found to bear at least part of the responsibility to follow up the next day.

If you are not called back, you must take the initiative to contact the retinal specialist. Offer to see the patient, and document that you offered to provide appropriate advice with regard to management of the orbital and soft tissues and the presence of the missile lodged in the orbital apex. By contacting the retinal specialist and/or seeing the patient the next day and continuing the appropriate oculoplastic care, you bring closure to the case with respect to your involvement. More importantly, your documented communications with the retinal specialist and the patient instill confidence that two collaborating specialists are managing the case appropriately.

Conclusion

I was asked once to contrast how a physician’s practice differs from that of a lawyer. I thought about it and answered that in a way, physicians are storytellers. Each new patient gives us the opportunity to write a new story. We take pride in our stories because, after all, we want them to serve as a testament to our skill as a physician. The practice of a lawyer is to read and interpret our stories to a jury; however, operating in an adversarial rather than a collegial environment, the lawyer may pick apart the story, quote things out of context, and try to shape the story as a subject of controversy and pain.

It behooves each of us as consultants and treating physicians to write brief, accurate, factual short stories and to hope that by doing so, most of them will have happy endings.