Keeping The Doctor In The Know

Call it being overzealous. Call it a misplaced work ethic. Call it playing doctor. Whatever you call it, make sure those on your staff know when to call the physician.

Dr. O is an ophthalmologist who was treating an 18-month-old boy for ptosis. A premature child with several other congenital abnormalities, the boy developed an acute strabismus, which Dr. O corrected with two surgeries. When the child reached 3-1/2 years of age, Dr. O performed surgery to lift the droopy eyelid.

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After the surgery, Dr. O prescribed one tube of Maxitrol steroidal treatment to keep the eye moist, with the intent of changing to an artificial tear ointment when the steroid tube ran out. Three months later, however, Dr. O’s nurse approved a refill of the steroid because the patient’s mother said that insurance covered the Maxitrol, but not over-the-counter tear ointment. The nurse approved (and charted) refills of the Maxitrol five more times over the next nine months.

While Dr. O continued to see the patient for residual strabismus, he began noticing excessive drying and decreased vision in the patient’s right eye. The parents also reported that the child battled them when they attempted to administer the medication. At nearly 18 months after the resection, Dr. O noted a dense, totally opaque cataract in the right eye. Dr. O discussed with the parents the need for cataract surgery, but the parents stopped returning.

A subsequent treating physician charted that the cataract was “probably secondary to chronic steroid ointment” applied after the eyelid repair. The subsequent lawsuit contended that Dr. O was negligent in authorizing the continued steroid treatment or in being unaware that his nurse was renewing the steroid prescriptions.

During the work-up of the litigation, Dr. O contended that he knew of the continued use of the Maxitrol. The expert reviewers were not so sure: Dr. O’s chart contained no rationale for the continued steroid use and the mother contended that Dr. O seemed “surprised” that steroids were still being used when the cataract was discovered. The case ultimately settled through the funding of an annuity for the boy.

A physician’s best employees always want to help the doctor’s patients. But a medical office is not a Nordstrom. The training for all office medical personnel necessarily includes an orientation to scope of patient care and the limits of that care. The individuals working in the suite must have a clear understanding as to when their clerical or patient duties end – and when the physician’s job begins. Protocols established by the physician help define those limits and can prevent an overzealous staff from exposing the physician to liability.

The physician’s attitude when interrupted can also send a strong message, be it “I am too busy for that kind of question” or “You were absolutely right in coming to me.” The staff must feel comfortable asking for help when questions arise outside the protocol or the established scope of care.

Physicians know that, by and large, they are responsible for their employees’ actions. Creating a system in which areas of responsibility are clear – and communication is welcome when they are not – can nevertheless help avoid the need for anyone to take the heat.

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Gordon Ownby is general counsel of CAP-MPT. Comments on Case of the Month can be directed to gownby@cap-mpt.com.