Some time ago a brief account of a substantial malpractice settlement appeared in a medical-legal bulletin. The case was unusual because one of the two defendant neurosurgeons had never laid eyes on the patient. The doctor was a sign-out colleague of the patient’s treating neurosurgeon.
A 35-year-old male with chronic heart condition developed lumbar disc disease and was referred to the neurosurgeon who performed bilateral L4 and L5 microscopic intralaminal decompression and disc exploration, without intraoperative complications. A few days postoperatively, the patient had a high fever and purulent drainage from his incision site. The operating neurosurgeon was out of town attending a medical conference, and he had asked a peer neurosurgeon to cover his patients’ care.
When called by the nurses, the covering neurosurgeon was also unavailable, having forgotten his agreement to cover the operating neurosurgeon’s patients. The patient’s wound infection, without recognition and treatment, escalated into sepsis. Because the sepsis was coupled with his heart disease, the patient expired.
In trial, the jury determined that full responsibility for the lapse in patient care was held by the operating neurosurgeon, as he should have taken steps to ensure adequate coverage.
Lessons to Learn
What lesson can be learned from this case? It is necessary to establish a working relationship with physicians who will be covering patient care in your absence. Verify their availability, commitment, and lack of conflicting duties.
The following sign-out guidelines will provide better care and reduce the possibility of legal action in sign-out situations:
- Choose your sign-out colleague with great care on the basis of competence and proven sense of responsibility rather than merely convenience and availability.
- Unless it is impossible to do so, always sign out to someone in your specialty. If you are the only doctor of that specialty in your community, arrange for coverage by a peer in a close neighboring community. Failing that, sign out to someone with sufficient understanding of your work who can handle any emergency that might arise.
- If the situation permits, have a second backup physician available in the event that your first choice sign-out colleague is temporarily unavailable. This is particularly important if the covering doctor is likely to become involved in lengthy operations or procedures that prevent him or her from immediately responding to your patients.
- Always choose someone who has privileges at your own institution, or arrange for that physician to have temporary privileges. If possible, you should both share the same telephone exchange.
- When you sign out, it is your legal obligation to warn your counterpart of potential problems during your absence. In particular, relate your evolving concerns about any patient that might require special attention.
- Whenever possible, alert your patients and introduce your sign-out colleague to your hospitalized patients. Remember, your patients have a special rapport with you. An unfamiliar doctor, regardless of competence, can create considerable anxiety, particularly if your substitute suddenly appears unannounced. Most patients feel that no one really understands their problem as well as their own doctor. You can put your sign-out colleague at a significant disadvantage by saddling him or her with an apprehensive or even hostile patient or family.
- If you work with house officers or moonlighting residents, inform them of your sign-out colleague’s name and telephone number. Regardless of their competence, however, do not sign out to them. In case of a trial, the jury would most likely interpret your choice of substitute as providing inappropriate care.
- As obvious as it may seem, do not forget to inform your exchange of who will care for your patients and for what period of time. Do not rely on someone else tttto do the informing.
- As soon as possible after you resume care of your patients, find out from your sign-out colleague if anyone experienced serious or unusual problems. If so, contact those patients immediately to assure them of your concern. If your patients express any dissatisfaction with your colleague’s treatment during your absence, resolve those problems immediately.
- In cooperative sign-out groups where doctors take calls for the entire group on a rotating schedule, be especially careful that the on-call physician is apprised of all problem cases. He or she should also know how to contact each member colleague if that proves necessary.
- If someone signs out to you, remember that you have accepted the responsibility of caring for that doctor’s patients as if they were your own. The fact that you are merely temporarily substituting for the patient’s regular physician does not relieve you of liability should something go wrong. To the contrary, you may be held culpable, while the absent doctor might be completely exonerated. In accepting an emergency call, always explain that you are not familiar with the patient’s history and suggest a follow-up visit when the records become available to you. Be sensitive to new-doctor shyness and make an effort to put the patient at ease.
- You and your sign-out colleague should have a clear understanding of how medical services are to be billed prior to treatment. If the substitute doctor plans to bill your patient directly, you should inform your patient of that arrangement before the bill is sent.
- Documentation of phone calls, patient visits, and any covering task is essential for continuity of patient care.
John A. McRae, MD, a retired neurosurgeon in southern California, is a member of The Doctors’ Company Board of Governors.
Joan Bristow, RN, MA, is vice president of TDC Risk Management. TDC offers malpractice insurance at a reduced rate to AANS members: www.aans.org/membership/practice/doctors.asp