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

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?

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.

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.

>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.

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!

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).

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.

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?

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.

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/

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.

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.

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.

"Will no one rid me of this meddlesome priest?"

Plausible deniability for authority figures is and has always been a thing.

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..

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-medic...

It's not clear what other remedy than a lawsuit would work in such a situation.

Hopefully medicine 3.0 will be better.

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.

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.

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.

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.

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.

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."

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.

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?