Re: EFM
From: Joe (forcep@intercom.net)
Fri Jul 13 06:01:09 2007
Negligence arises from system failures. Joe C
D. Ashley Hill wrote:
> Thanks for the comments. Our department chairs have the authority to
> suspend privileges instantly if there is concern about quality of care.
> At that point they likely would delegate care to the on-call physician
> or assume care themselves.
>
> I have seen a lot of interesting variations of the chain of command,
> from disagreements about seemingly benign aspects of care (for example,
> whether to give a medication BID or TID) to concern about shocking
> deviations from universal standards of care. Interestinly, in almost
> all cases, when the division or department chief reviews the case and
> talks with the attending physician, he or she usually acquieses as if
> "you caught me." I agree with others that every department needs a
> formal chain of command with predetermined "rules of engagement."
>
> I have seen this concept presented analogous to the airline industry.
> Many years ago the airline industry had a landmark accident (I can't
> recall the details, but I think it involved ice on the wings) where
> several flight attendants and others noticed a problem but either were
> afraid to approach the captain or assumed he, being the boss, would
> already know about the problem. In the healthcare industry the doctor
> used to be king. It's safer to have everyone focusing on patient safety
> first, without regard to physician ego. Thanks again.
>
> Ashley
>
> At Thu, 12 Jul 2007, William D. McIntosh, M.D wrote:
>
>>While your point is taken, and there is no doubt that there are a few
>>bad docs making lots of bad decisions, and a lots of good docs making
>>occasional bad decisions, I cannot see myself as Chief walking into a
>>patient's room, a patient that I have never met, and declaring that
>>because there is a REASONABLE difference of opinion on her management, I
>>am terminating her care by her chosen physician, and substituting my own
>>plan. There is neither legal nor moral authority for that in any
>>hospital bylaws. Remember the case we are discussing, and that we are
>>talking about a difference of opinion on management, not neglect or
>>incompetence. Not the same thing at all. For what its worth, our
>>bylaws here include no provision whatsoever for the Chief to wrest the
>>control of a patient from the attending.
>>
>>As an aside, I am not criticizing the nurse pursuing this issue up the
>>chain of command. That is what the chain is for, the protection of both
>>the patient, and the concerned staffer. She did what she needed to do,
>>but the fact that she complained does not make the charge proven, as Joe
>>so eloquently noted.
>>
>>William D McIntosh, MD FACOG
>>
>>Clarksville, TN
>>
>>-----Original Message-----
>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of D.
>>Ashley Hill
>>Sent: Wednesday, July 11, 2007 9:40 PM
>>To: Multiple recipients of list OB-GYN-L
>>Subject: Re: EFM
>>
>>Many hospitals have bylaws that every physician on staff subscribes to
>>
>>as part of membership. These may include mandates that the chief of the
>>
>>department (and certainly the chief of staff) has the authority to
>>
>>override clinical decisions by the staff physician if the chief
>>
>>determines that care is not in the best interest of the patient.
>>
>>Hopefully hospitals have formal policies for this and structured
>>
>>committees to evaluate these types of complaints.
>>
>>Let me add another direction to this discussion. Over the years I have
>>
>>seen physicians (mostly at hospitals other than my own, but some here)
>>
>>try to put vacuums on breech or face presentations, try to induce 34
>>
>>week patients for no other reason than they were leaving town for
>>
>>vacation, and attempt to perform major surgical procedures that they did
>>
>>not have any training or privileges to perform (think breast
>>
>>augmentation). The chain of command worked in these (thankfully rare)
>>
>>situations and those physicians were both stopped from harming patients
>>
>>and provided with an impetus for remediation (get remediation or don't
>>
>>come back). Not all physicians are as skilled as or ethical as you are.
>>
>>I dispute your argument that there is no legal standing for the
>>
>>department or hospital chief to intervene in the care of your patient
>>
>>when he or she feels, after careful review, that your care endangers the
>>
>>patient. Likely, you signed something to that effect when you signed on
>>
>>for medical staff privileges. Best wishes,
>>
>>Ashley
>>
>>At Wed, 11 Jul 2007, William D. McIntosh, M.D wrote:
>>
>>>If the current Dept Chief wants to take over the management of one of
>>
>>my
>>
>>>patients without my permission, he had better bring a sack lunch and a
>>
>>>lot of help, because it is going to be a long, hard day. He has no
>>
>>>legal or professional standing to overrule my management as long as I
>>
>>am
>>
>>>physically and mentally competent. He might not like my plan, and my
>>
>>>privileges might be challenged later, but the relationship between my
>>
>>>patient and me is not open to review by my hospital. SHE can fire me,
>>
>>>or SHE can sue me, but the poor sod stuck with Dept Chair has no
>>
>>>jurisdiction over that relationship. Management might be open to
>>
>>>debate, but in the end, I would be the only doctor in the room with a
>>
>>>doctor-patient relationship (in both the legal and professional
>>
>>senses),
>>
>>>and that relationship can only be altered by the direct participants.
>>
>>>For that matter, if he were to touch the patient without her
>>
>>permission,
>>
>>>would that not constitute assault?
>>
>>>--
>>
>>>William D. McIntosh, MD, FACOG
>>
>>>Clarksville, TN
>>
>>>-----Original Message-----
>>
>>>From: ob-gyn-l@obgyn.net [mailto:ob-gyn-l@obgyn.net] On Behalf Of
>>
>>Robert
>>
>>>J. Carpenter, Jr. MD, JD
>>
>>>Sent: Tuesday, July 10, 2007 7:50 PM
>>
>>>To: Multiple recipients of list OB-GYN-L
>>
>>>Subject: Re: EFM
>>
>>>Given facts of the case, your responsibility as service chief is
>>
>>>evaluation of the nurse's
>>
>>>concern as chain of command decision-maker. If you agreed with the
>>
>>>nurse, then
>>
>>>discussion with the attending MD about your agreement is mandated.
>>
>>>If he did not agree to C/S, then you could/should take over management
>>
>>>after
>>
>>>discussion with the patient concerning the events, findings, and the
>>
>>>differences in
>>
>>>opinion. If you do not agree with the nurse then you have fulfilled
>>
>>your
>>
>>>duties and
>>
>>>continued management of the labor would be appropriate.
>>
>>>If following the delivery, the nurse's opinion is validated and
>>
>>>continued vaginal delivery
>>
>>>was allowed, then you may have to explain why you made the decision you
>>
>>>did and
>>
>>>failed to intervene. On the otherhand, if the baby is severely
>>
>>impaired,
>>
>>>you may have to
>>
>>>prove that the interval from your consultation to the penultimate
>>
>>>delivery, did not
>>
>>>change the outcome of the patient.
>>
>>>It is not an enviable situation to be in but been there, done that, and
>>
>>>I have both
>>
>>>intervened and continued current management. As Mr. Truman said: "The
>>
>>>buck stops
>>
>>>here." True for all of us in chain of command status.
>>
>>>Look fwd to the outcome
>>
>>>Robert J. Carpenter, Jr. MD, JD
>>
>>>6624 Fannin, #2720
>>
>>>Houston, TX 77030
>>
>>>(O) 713-795-4600
>>
>>>(F) 713-795-4422
>>
>>>"Life is difficult"
>>
>>>The Road Less Travelled
>>
>>>by Scott Peck
>>
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>>
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>>--
>>
>>D. Ashley Hill, MD
>>
>>Associate Director
>>
>>Department of Obstetrics and Gynecology
>>
>>Florida Hospital Family Practice Residency
>>
>>Medical Director, Loch Haven Ob/Gyn Group
>>
>>Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
>>
>>Orlando, Florida
>>our patients' personal information.
>>
>
> --
> D. Ashley Hill, MD
> Associate Director
> Department of Obstetrics and Gynecology
> Florida Hospital Family Practice Residency
> Medical Director, Loch Haven Ob/Gyn Group
> Division Director, Dept. of Ob/Gyn, Florida Hospital Orlando
> Orlando, Florida
>
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