In the push towards multidisciplinary general practices where patients “commit” to a practice, one concern has been obscured – if not lost completely.
The medical indemnity providers have been very, very clear that if we GPs receive a letter from another health professional, we are responsible for the health of “our” patient.
In other words, we accept duty of care.
So what do we do if “our” patient has seen another primary care professional, and we have no idea how concerned to be? Are we responsible for recalling everyone? Some of them? None of them? It’s all a little worrying.
With emergency departments, we can generally gauge how concerned to be, mainly because we know and trust that there has been medical review.
The medicolegal advice around test results is generally that if it lands in your inbox, and it is abnormal, you need to ensure the patient is managed appropriately. However, we all have stories of patients who “slip through the net” and are harmed because the patient never turns up, and neither does the discharge summary.
The situation is less clear with the urgent care clinics.
Avant, in its advice, says that “If the UCC doctors do not have the capacity to continue to provide ongoing GP care, either in their UCC capacity or co-located GP practice role, this should be explained to the patient with the advice that they see their old GP or locate a new one. This should be confirmed in a letter to the patient with a copy of the discharge summary to be given to their doctor”.
But what happens if there is no doctor at the UCC and the discharge is summary is lengthy, unstructured and written by someone you do not know, or by someone whose qualifications are not able to be understood by you?
Here’s a case in point, constructed with a few examples to preserve confidentiality.
I receive a letter from the nurse-led clinic with 10 pages of extensive negative findings about a child who presented with a fever. The child has been examined and the diagnosis at the end of the letter said the diagnosis is “likely viral infection”. No urine test has been done. The letter is signed by an “Advanced Practice Nurse”.
An Advanced Practice Nurse has to have had 5000 hours of “clinically based advanced practice” in the last six years. As far as I know, this does not need to be in primary care.
The nurse signing this letter may be supervised by a nurse practitioner or may be working independently. Her special interest may be in cardiology.
I know there is no doctor in the nurse-led clinic. From a medicolegal perspective, then, I am not reassured by her assessment, and probably should recall the child who, in my world, would be classified as having “pyrexia of unknown origin”.
Related
That is frustrating, but it’s worse when there is no letter at all.
I recently cared for an immunosuppressed patient who was diagnosed with a UTI on the basis of dysuria, non-specific pelvic pain and low-grade fever at the local pharmacy. She received two consecutive courses of antibiotics, but obviously no examination of her or her urine.
The pharmacy does not seem to send any notifications to us, and did not seem to think her immunosuppression was clinically relevant. Prior to the antibiotics, she was given an antifungal cream, because she thought she had “thrush”.
Ten days after the first presentation, she leaves a message with reception that she “has a UTI and the antibiotics aren’t working”.
Because of the immunosuppression I (thankfully) recall her, and discover she is quite unwell.
On examination, she has florid primary herpes simplex and is admitted for catheterisation because she now has more than “dysuria” – she cannot void at all. It is too late for antiviral therapy, but she is given it anyway in the hope it will reduce the chance of relapse.
The question is, who is medicolegally responsible for her, and at what point? Let’s say I assumed she was seen by a doctor, would that have changed my approach? Should it?
The pharmacists mostly followed their protocol (expect for the second course of antibiotics) so are they absolved of their medicolegal responsibilities for the complications?
Is it my patient’s responsibility to assess whether to see a doctor? Or is it that she should have picked a different health professional because she should have known this was complicated?
Here’s another one. An insurance company denies a worker’s claim. This worker has PTSD secondary to a workplace-based highly distressing exposure.
They have been accessing funding through their insurance company for treatment for their PTSD and later substance misuse. This time, the insurer decides to deny an inpatient admission, because he “hasn’t benefitted from previous admissions” and there has been “no appreciable improvement in outcomes”.
The assessor suggests that I break this news to him as “we recognise this person is highly vulnerable and would like his GP to manage the release of this finding so his wellbeing is supported”.
They then ask me to let them know when I’ve done that, so they can update their records. There is an extraordinary logic here: I am supposed to “support their wellbeing”, which given their vulnerability, really needs to be an admission.
However, the insurance company have made sure an admission is not possible. So how on earth can I “support their wellbeing” when the insurers have denied the resources to do so?
In all of these situations, I have assumed medicolegal responsibility for a patient who is, in all cases “mine”, although in the current environment, being “mine” is not as well defined as it will be under MyMedicare.
In all cases, I have had to invest unpaid time and labour assessing risk on the basis of someone else’s documentation, or lack of it.
I have had to find time to recall the patient and basically redo the assessment and I have assumed the medicolegal risk.
If the patient died, in all three cases, what liability would I have? History suggests there would be enormous interest from the coroner, and considerable time and angst for me.
I suspect the first two clinicians would be absolved by their respective Boards, because both would have followed their “appropriate protocols” even though the protocols were dangerous for both patients.
Suffice to say, I do not want this medicolegal risk.
It’s hard enough managing my own risks, without assuming the risks of other clinicians who do not work directly with me. In the case of pharmacy, they do not involve me at all in the clinical decision making but assume I will manage anyone who is outside their protocols.
My indemnity insurance is high enough, well above the $200 a year paid by other professions.
I have enough chaos managing my own patients. I did not consent to be the safety net for the entire health system.
Associate Professor Louise Stone is a working GP who researches the social foundations of medicine in the ANU Medical School. She tweets @GPswampwarrior.
