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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
What counsel?
"Himmattey mar-daa mududdey khudaa" ("Almighty helps the man who takes up the challenge")
THE SULKING GP. WHERE ARE WE GOING?
Making Better Law
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Tara J. Lindhardt, Ramona, California Student/ Mother of Disabled Child
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I am the mother of a medically fragile developmentally disabled child and here is my experience: I was seated at this huge circular table with several medical professionals after my child had a tracheotomy and told now it is time for him to get out of the hospital (he had been there for eight months after his birth with an "unknown syndrome"). I was told I was very lucky that the particular general practitioner who took my case was willing to do it because of the high liability. While we have stayed with this particular GP for my son's entire life he has done nothing at all to coordinate care for my son who has numerous medical issues. I have had to identify each issue and ask for insurance authorizations (which he is good about getting). As a layperson I have had to practically become a doctor, a lawyer and an education specialist. If I am not able to identify a possibly life threatening issue then my son's life is at stake. Additionally in terms of liability because my insurance will only pay for LVNs I must do all the RN care. Actually, my family has been very successful although it has been tough and we do like our GP...great bedside manner and he was also the pediatrician for my well child but my question is how can laypeople parents without any professional training and oftentimes in the throes (especially early on) of the grief process possibly be expected to do so much without significant assistance in coordination by the doctor? I have seen many many families with poor outcomes for the child and the rest of the family because of this stress. Thank you for any responses. After seventeen years I wonder how to make things better. I believe doctors want to help their patients and work with them in partnership and I think all these liability issues do get in the way with serious consequences. Competing interests: None declared |
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Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS., Agra. INDIA Consultant, Family Medicine & Communicable Diseases.
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Dear Editor, Having read the article dealing with ‘Liability Implications of Physician-Directed Care Coordination’ by Hall et al [1], I had submitted an earlier response, "The sulking GP. Where are we going?" Maybe we can do better than getting dampened by liability implications. I remember that nearly 20 years ago while I was serving at a really cold and remote area situated at around 14000 feet, a man came seeking my help. His wife had been in labor for over a day with their first child, and he wanted my help for the delivery. While he was requesting my help, I could not take my eyes off the small shining dagger that was hung around his waist, which virtually forced me into listening. My clinic did not cater for deliveries and neither had I any requisite instruments or equipment. There was a hospital with proper staff, but it was half a day’s walk for them in this precarious situation. Therefore these men expected me to accompany them to their small village where this lady was, to conduct the delivery. With only about two years of experience then, I had expected my boss would turn their request down; to this day I cannot figure why he did not. It was a really tough job at hand with no backup facilities and with no chances of backing out. In that hour of crisis, I requested my colleague who was an hour away to come and assist me, and we converged on the village at nearly the same time, with my personal assistant in tow. We carried with us some medical supplies. These however did not include Injection Pitocin or Methergine, as we never had them, and for instruments I had only a venesection set to bank on. I was sullenly sure that there was to be no legal battle if we failed. We found ourselves in a very small temporary hut, which was to be the labor room and nursery, with no lights and no space around the bed on which this lady was lying exhausted. She had a low blood pressure and it took us time to infuse IV fluids because they had to be defrosted first. The head had crowned and luckily the foetal heart sounds were still audible, although slow and very faint. We asked the neighbors for a torch, warm water and for the room to be heated. Then with her husband and my assistant throwing me the torch light, I performed an episiotomy at the next pain and delivered the baby. My colleague very efficiently took over resuscitating the newborn while I continued concentrating on the mother, who had lapsed into uterine inertia. With the third stage not completed, I could not stitch her up and thus the episiotomy added to further blood loss. Suddenly I remembered my revered teacher, Dr. Shiv Ramakrishan, having told me of an outdated maneuver of sweeping the whole of the palm, thereby dislodging the placenta. With no other alternative available, that ancient maneuver helped in completing the third stage and allowed me to suture her up. The newborn’s cries were now a melody to me. The infant had been very well taken care of by my colleague, who had raised the APGAR from 5 to 9. We felt relieved and enjoyed a cup of good strong tea in yak’s milk with plenty of sugar, which the neighbors had offered. Regular follow up care was provided and I saw the child become a handsome toddler before I was sent off to another clinic. Although I am not a Moslem, my belief in one of their sayings which means that the almighty helps those who take up the challenge was further re-strengthened. This has been my view ever since and I continue using whatever knowledge and skills that I have with zeal, commitment, enthusiasm and without worry or fear, so long as I am sure that I am doing just the right thing for the sake of a patient. This is what I sometimes tell my junior colleagues. With regards. Dr. Rajesh Chauhan. Competing interests: None declared |
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Dr. Rajesh Chauhan. MBBS, DFM, FCGP, ADHA, FISCD, FAIMS., AGRA. INDIA Consultant, Family Medicine & Communicable Diseases., Dr. Akhilesh Kumar Singh. MBBS, MD (Sr Res Neurology). Dr. Parul Kushwah. MBBS, MISMCD. Sandeepa Chauhan. MA. Shruti Chauhan. Shivendra Pratap Singh Chauhan.
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Having read the analysis by Hall MA and colleagues [1] we would like to submit the following. We probably want good lawyers to take good care of the health needs in this era of liability and the mortal fear of being sued. Yes, after having graduated doing law, a person can join medical school since he or she would not be so worried thereafter by virtue of their initial grooming, as normal doctors are. This ought to become an essential prerequisite for gaining an entry to a medical school. The lawyer need not worry about mind blowing medical studies as the studies would be very concentrated on one particular sphere and therefore essentially hassle free. There would not be any requirement of having to read everything from head to toe, since the choice is clear- either become a GP or a superspecialist. If the lawyer, the ‘new age doctor’ (NAD) chooses to become a GP, then there would be practically no requirement of further studies as all that would be required of the NAD would be to transfer or refer. This is what most GPs are doing despite knowing almost everything, and hence NAD must not suffer remorse. Moreover patients are not interested to seek his or her opinion and advice and are also never satisfied by a GP. Well if this NAD wants some challenging medical practice, then also the NAD would not require extra studies; albeit a concentrated study in one sphere alone would be required of NAD to do well, since anything extra would never be utilized, beyond what is within the direct ambit. For this challenging career, the choice would practically be unlimited. For example the learning process may involve not the complete gastrointestinal system and therefore foregut, mid, hindgut, the terminal end or any of the junctional parts may be chosen for medical study. Hordes of other choices loom ahead for this practitioner. These are within the fields of medicine, surgery, pathology, physiology, microbiology, radiology, paediatric, geriatric, forensic, oncology, etc. Now if this NAD prefers a combination of mid gut - geriatrics with radiology for superspecialization, he or she would further have the choice of invasive, interventional, etc in radiology itself. Therefore, from this example, what is the use of knowing about foregut, or for that matter the junctional part and similarly no need for knowing the problems in children or adults, as geriatrics is what the NAD is proficient and qualified in. The lawyer should not worry not having studied the complete human body, and the basics of medicine, surgery, gynaecology, paediatrics, forensic, anatomy, physiology etc, which a person has to otherwise learn for becoming a doctor. The reason being quite simple- all doctors despite having sufficient knowledge are unable to practice what they know for fear of a law suit. Words of caution for the lawyer- no need of bravado and trying to do things known or qualified, but otherwise not pertaining to the discipline the lawyer now belongs to. Patients and other lawyers (not in the medical stream) may be waiting for just this opportunity. Probably the above scenario hints at a number of lingering questions regarding professionalism, doctor-patient relationship, ethics, morality, sound knowledge and matching qualifications, creation of superspecialities, outdating of general practice, growing expectations, market forces, clientele satisfaction, etc, and worst of all- the mortal fear of being sued and libeled. The NAD being a lawyer by background, would therefore be more safe and secure and would be able to practice with dedication and devotion to whatever responsibility he or she chose to undertake – be it GP or a superspecialist. With regards. •Dr. Rajesh Chauhan MBBS, DFM, FCGP, ADHA, FISCD, FAIMS. Consultant, Family Medicine & Communicable Diseases. •Dr. Akhilesh Kumar Singh MBBS, MD (Sr Resident Neurolgy). •Dr. Parul Kushwah MBBS, MISMCD. •Sandeepa Chauhan MA. •Shruti Chauhan •Shivendra Pratap Singh Chauhan Reference: 1. Hall MA, Peeples RA, Lord Jr RW. Liability Implications of Physician- Directed Care Coordination. Annals of Family Medicine 2005; 3: 115-21. Competing interests: None declared |
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Richard G Roberts, Madison, WI USA Professor of Family Medicine, University of Wisconsin
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Invited Commentary The manuscript by Hall, Peeples, and Lord on liability issues for physicians who coordinate care provides additional evidence that physicians’ fear of litigation is greater than the reality. This is good news, given that physicians identified liability concerns as one of two major barriers to providing coordination of care services in a study by Anderson(1). The adverse health and cost implications of chronic conditions pose significant challenges, with several strategies proposed to improve their outcomes. For example, disease management has been offered as a specialized scheme to manage intensively select chronic conditions, while involving the patient’s primary care physician to varying degrees. Strategies that diminish the role of primary care physicians in chronic care are unlikely to succeed long-term. Many with chronic conditions have more than one health problem – the care of those multiple problems must be coordinated. Numerous studies show that increasing specialization causes a decrease in a population’s health status and outcomes (2). Patient safety studies suggest that more caregivers result in more communication errors, which comprise the majority of medical errors in today’s increasingly fragmented care system (3). Those with chronic conditions do better when primary care physicians coordinate their care. When the occasional court makes inappropriate judgments about coordination of care and imposes liability, primary care physicians should not respond by narrowing their efforts on behalf of patients – bad law does not make good medicine. More importantly, the findings of Hall et al. suggest that good medicine (coordination of care) may make better law (lower liability risk). It is important to note however, that the conclusions of Hall and colleagues are based on, and limited to, a reading of what has been (past case law) and what experts believe might be. Liability risks that appear inconsequential today may loom large tomorrow; the law is as dynamic as medicine. Successful lawyers are inventive and will advance new theories of liability to reflect changing social realities and medical capabilities. When care is coordinated in a competent and conscientious manner, patient outcomes will improve and legal risks will diminish. When care is coordinated badly, patients will suffer and liability hazards for physicians will increase. The Hall manuscript only goes part way in helping primary care physicians overcome barriers to coordination of care. While liability concerns were the #2 barrier in the Anderson study, the #1 concern was adequate reimbursement for coordination of care services (4). One down and one to go. Richard G. Roberts, MD, JD Professor of Family Medicine University of Wisconsin Medical School REFERENCES (1) Anderson GF. Physician, Public, and Policymaker Perspectives on Chronic Conditions. Arch Intern Med 2003;163:437-442. (2) Starfield B, Shi L, Grover A, Macinko J. The Effects of Specialist Supply on Populations’ Health: Assessing the Evidence. Health Aff (Millwood) 2005 Mar 15;W5:97-107. (3) Woolf SH, Kuzel AJ, Dovey SM, Phillips RL Jr. A string of mistakes: the importance of cascade analysis in describing, counting, and preventing medical errors. Ann Fam Med 2004 Jul-Aug:2(4):292-3. (4) Personal communication, Gerard F. Anderson, PhD, 23 March 2005. Competing interests: Vice Chair, Physicians Insurance Company of Wisconsin |
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