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Comment by amputect | Hacker News Reader

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.

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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.

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.

The NP did not try to do the right thing. Given the facts outlined in the article, a qualified medical professional would have sent the patient to a hospital (emergency room) regardless of the opinion of the consulting MD's who did not see the patient. Why? Because the NP did see the patient. Why take an off the cuff opinion of a MD who hasn't examined the patient or seen his charts (all info was given verbally over the phone) as absolute? Note, many seem to interpret the refusal of admission as an inability to go to a hospital, that is not the case. The emergency room was still available.

IMO, there was failure at all levels. The NP failed, the consulting doctors failed, the hospital chain failed. Systemic failure.

Except they all seem to be part of the same company so I assume they have rules saying that the NP needs to give the Dr’s opinion more control over the decision. After all it sounded like they contacted multiple (of the company’s) drs and they said the same thing.

If they are part of the same network the dr probably had access to the charts, and if not I assume nurses who are required to call doctors can communicate the content of a chart.

It also makes no sense to say: NP you are required to contact a doctor to get permission to admit a patient, but if you think the doctor is wrong you should admit them anyway. If that isn’t the rule then you should save money by not having drs who only exist to answer the phone and trust you NPs to admit patients who need it.

> Why take an off the cuff opinion of a MD who hasn't examined the patient or seen his charts (all info was given verbally over the phone) as absolute?

While it doesn't change the overall point much, she didn't take the opinion of an MD that way; after getting the response from yhe hospitalist, she attempted to bypass the refusal by taking the case to a physician at her own clinic who had admitting privileges at the hospital, but who reached the same conclusion as the hospitalist had.

The nurse was sued as well -- but I agree, she's just as liable as the doctor.

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.

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?

> The NP in this story is one of the people that fucked up.

And was sued for it and presumably (the case with regard to her was settled on undisclosed terms) forced to pay. But she fucked up by passively accepting the judgement of the MDs involved, so the upthread comment that this case might encourage (or “legally motivate”) NPs to act more independently is reinforced rather than negated by the fact that the NP fucked up and was held to account here.

> and yet he's vulnerable to a malpractice suit, and the NP is not.

You mean “he got out of even having to face malpractice liability at the trial and first appellate level, while the NP was forced to settle before even reaching trial.”

Not a medical professional, but if you're positive that the patient is going to be admitted then bypassing the ER may make a lot of financial sense for the patient. Going to the ER is expensive, so moving directly to admitting cuts a lot of cost.

If you don't believe me and are in the US, call your insurance company and ask "what's my out of pocket if I'm admitted to the hospital for 1 night going through the ER vs going through an urgent care center?" There's a pretty good chance the ER route will be at least $1000 higher.

Urgent Care centers do not have hospital privileges and cannot admit to the hospital. If they think you need hospitalization, they send you to the ER.

Bypassing the ER is a good way to have your insurer try and deny coverage, since you’re giving them a plausible case that it wasn’t an emergency.

Urgent Care centers do not have hospital privileges and cannot admit to the hospital.

That surprises me since (at least in my area of the Chicago suburbs) all of the urgent care centers I've seen are associated with hospitals or hospital networks. I have no experience with their admitting capabilities though, having never actually used one.

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.

It depends on how many hours they've practiced. Initially, under a physician. Eventually, completely independent. The article describes the second doc as a "collaborating physician," but I went to the underlying court documents and, no, they were just a second informal consult - this NP was practicing independently.

The case isn't that unusual. Malpractice lawyers name everyone even tangentially related to a case, because malpractice insurance has a cap on payouts and you'll never go to court and win more than that cap, so you want to pull in as many people's policies as possible. Everyone that wasn't directly involved in the care of the patient gets their names dropped from the suit pretty quickly. Normally.

So, it's not unusual that the person that actually fucked up (the NP) settled, and someone not part of the patient's care said screw that (the MD).

Docs also don't choose for themselves whether they fight it in court. The malpractice insurer does. If you go against the insurer's wishes, you basically give up your malpractice coverage. In this case, I'm guessing that the fact that this is a slam-dunk "get thrown out of court" situation is why they didn't settle, as they do the vast majority of the time, regardless of the underlying merits of the case. Usually settling is cheaper than litigating, but a single "get this thrown out" motion is cheaper than settling.

The unusual thing here is just that MN is somewhat unique as one of the few states that doesn't explicitly require a doctor-patient relationship for its malpractice suits, so instead of getting thrown out, the case is going ahead.

Umm, he hasn't lost, at least not yet.

What he lost was the appeal of the dismissal of the case. The MN Supreme Court ruling merely means the case will go to trial. He may yet prevail, but from what I read in the article, seems to me that it's unlikely he will prevail.

Edit: spelling

I am sure they dream of AI diagnosis. It can be optimized for profit and any negative effects can be blamed on the AI.

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.

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