Sunday, June 15, 2008

ER call ethics

I was recently asked to comment on this article written for the blog Brain Blogger (shortened version below, I encourage you to read the full article):

In a fit of rage, a thirty year old otherwise healthy man punches a hole through his window.

Unfortunately, there is no hand surgeon in the community that takes on-call service for the ER. Thus, the ER doctor calls various community hand surgeons to see if they will take care of the patient.
Finally, the ER is able to get a hand surgeon who will answer his pager. The hand surgeon agrees to get involved with the care of the patient. He listens to the story over the telephone and feels in his best judgment that the patient will need an exploration of his hand in the operating room. Studies show that there is no difference whether this happens sooner or later as long as it is done within 24 hours. Thus he explains to the ER doctor that he is out to dinner with his family and won’t be able to see the patient until the morning. He tells the ER physician to either discharge the patient and have him come to his office in the morning, or to admit the patient and that he will see the patient in the morning.

Several ethical issues are raised later in the article and by commenters to the article, and I will only address a few of them, but I encourage comments.

1. I do not think that physicians have an ethical obligation to provide hospital/ER call. I think this is a matter of negotiation between hospitals and the doctors who apply for medical staff privileges. Hospitals have the right to refuse medical staff privileges to doctors who don't want to meet the hospitals' call requirements. Doctors have the right not to apply for privileges at hospitals that have onerous call requirements. To attract physicians of certain specialties, some hospitals may need to pay the doctors for taking call, though this is a legally tricky area.

2. Regarding the specific case, once the surgeon "agrees to get involved with the care of the patient", I think he is obligated, at least from a medicolegal perspective, to go in and see the patient that night. If he wasn't prepared to go in that night, he should have told the ER doctor that in general that type of injury requires surgery within 24 hours, but that he couldn't comment on the specific patient. If I was in that surgeon's place, I would have offered to see the patient in the morning, but made clear that the ER doc was responsible for the patient until then and that no doctor patient relationship would exist until and unless the patient arrived at my office. I would tell the ER doctor that if he was uncomfortable with that disposition, he could always send the patient to a university hospital/tertiary care center (if the ER doc thought the patient was stable for transfer).

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