Inadequate coverage arrangements can lead to abandonment allegations. Any time you are unavailable to your practice (e.g., on vacation, observing holidays, attending medical conferences, suffering from an illness, treating other patients, etc.) appropriate coverage must be arranged. The following case studies highlight the risks of poorly planned coverage.
Case File #1
While he was scheduled to be on call in the ED, a general surgeon attended a medical conference.1 The hospital bylaws required him to be available within 30 minutes when on call, which was not possible from the location of the conference. The surgeon arranged for an orthopedic surgeon to cover for him while he was at the conference but did not inform the hospital that he would not be available.
During the conference, a trauma patient was brought to the ED with severe injuries and internal bleeding. The orthopedic surgeon returned the ED physician’s page; however, he was unqualified to perform the necessary surgery, and he did not have privileges at the hospital. The patient was transferred to another facility for surgery, but the four-hour delay in treatment caused the loss of a kidney, gallbladder, colon and part of the small intestine. The patient sued the on-call physician, alleging among other claims, that his failure to treat her amounted to patient abandonment.
The case went to trial. The issue of whether a physician-patient relationship existed, and if so, whether an on-call physician could abandon a patient he had never seen, was considered by the appellate court. The appellate court found that a patient-physician relationship existed between the on-call surgeon and the patient by virtue of the surgeon’s being on call; and because the relationship existed, the surgeon had a duty to operate on the patient. Therefore, the appellate court found the surgeon guilty of abandonment for the four hours the patient waited for surgery.
Case File #2
Two physicians had a practice in a rural area.2 They alternated call nights. Only Physician 1 provided obstetrical care, but he was careful to always arrange to be on call for his obstetrical patients when they neared their due dates. He planned vacations only at times when he assumed no patients would go into labor. Unfortunately, while he was on a one-week vacation, a patient went into premature labor. She presented to the ED and the ED physician called Physician 2. Physician 2 informed the ED physician that he did not do obstetrics and advised the ED physician to find an OB. Unfortunately, the on-call OB for the only obstetrical practice in the region was in the middle of a c-section at Hospital 2. The OB told the ED physician to transfer the patient to Hospital 2. After various delays, the OB delivered the infant at Hospital 2, but the child sustained permanent brain injuries.
The patient sued Physician 1 on several grounds, including patient abandonment. Plaintiff’s experts stated that the standard of care required Physician 1 to be available for obstetrical emergencies, or to arrange for emergency coverage by the OB group. The case settled for a significant amount.
Although coverage of the physician’s on-call duties was arranged, the patient in this case was essentially left without a physician competent to handle her obstetrical emergency. In other words, she had been “abandoned.”
Medical Liability Risk Management Recommendations
Even if your coverage arrangements have been sufficient in the past, it is worth ensuring that your current arrangements will not expose you to claims of patient abandonment if something unexpected occurs. Consider the following strategies:2
- Advise patients of the special call challenges presented in rural settings and ensure that they know what to do in an emergency, when the office is closed and when you are otherwise unavailable.
- Have coverage policies and protocols in place.
- Ensure that the coverage physician can offer your patients equivalent medical services (e.g., do not have an internist provide coverage for you if you are a surgeon).
- Carefully discuss coverage details with the physician providing coverage and alert him or her to any unusual circumstances (e.g., that you were on call the previous evening and emergency patients may be showing up for follow-up appointments).
- Document specific directions and advice given.
- Provide your coverage physician with a list of patients who may need immediate treatment (e.g., patients in the hospital, being worked up, in the middle of intensive treatment, etc.).
- Provide all entities where you have on-call duties, your answering services and your own office staff with the name of and contact information for your coverage physician and the amount of time he or she will be covering for you.
- Make sure there is a mechanism for this information to be provided to patients who may need care during your absence. Patients need to know how to contact the covering physician when necessary.
- Concurrent with your return, meet with your coverage physician to discuss what occurred while you were absent, particularly any unexpected events or medical complications.
- Document relevant details.
- Review correspondence and messages and study reports received during your absence. Take special note of follow-up orders, appointments or studies to ensure continuity of care.
References
1. Case study derived from Millard v. Corrado, 14 S.W. 3d 42 (MO. Ct. App. 1999).
2. Lippman H, MA, Davenport J. Patient dismissal: The right way to do it. J Fam Pract. 2011 Mar;60(3):135-40. (accessed 5/30/2017)
