Commentary

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

I see other doctors as patients. Granted, other doctors also see me as a patient.

Seeing another doctor always adds an extra layer of challenge to the job. Even if they’re not in my field, I worry they’re secretly criticizing what I’m doing and thinking I’m clueless. Odds are favorable that they did a neurology rotation at some point, and so are at least somewhat familiar with the history and exam.

I suspect other doctors get bigger work-ups than nondoctors. Some of it may be for legal reasons, but I think most of it is that we figure they expect it from us (although, realistically, I’m not looking for a bunch of tests when I go to the doctor). As a result, more MRI scans and labs are ordered to search for both horses and zebras.

I can’t say that I’ve found weird or scary stuff in other doctors any more than what I’ve found in the general population, but somehow I worry more about missing something. Maybe some of it is the feeling that we’re all part of the same family, so I need to take care of brethren. Or a nervous feeling that they’re inwardly rolling their eyes and thinking that I’m an idiot if I don’t order a certain test. It might be more likely that they’re sitting there wondering why the hell anyone would want to be a neurologist because they hated their rotation in it.

When it comes to treatment, similar thoughts come up. Other doctors know the meds – although so does anyone with a smartphone these days – and I worry that, inwardly, they’re secretly criticizing my choice of poison or are going to argue with me about side effects.

Like any doctor, I want to give equal care to all. But human nature means different circumstances can change our mindset, and we have to overcome that. Good or bad, it’s part of the job.

Dr. Block has a solo neurology practice in Scottsdale, Ariz.

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

Thirty-five years ago my wife was the volunteer coordinator at the grade school down the street. She seldom had to do much coordinating because there weren’t many volunteers. My daughter-in-law currently holds the same position in the same school. And although she would always like to have additional volunteers, she manages many more than my wife ever did.

When I was a child, if I saw a parent in the school it was a bad sign. Either someone had gotten sick or some poor soul had done something that had put him on the path to expulsion. School was a treasured parent-free zone, my own little social laboratory where I could experiment with the person I was going to be when I grew up.

But now parental involvement is viewed as one of the keystones of child rearing. Parents feel they need to be active participants in their child’s schooling, and this has increased parental involvement in the classroom. This would seem to be a good thing, propelled partly by a genuine desire to help schools where resources are being stretched thin by budgetary constraints. But occasionally, volunteering is a misguided attempt to deal with unresolved, sometimes bidirectional, separation anxiety.

And I fear that sometimes volunteering is a cover story for spying. Most children are stingy with stories about their school days. "What happened in school today?" The typical response is "nothing special." Unless of course, "Rachel vomited on her desk during math this morning."

I have always suspected that parental involvement is a double-edged sword. And some recent work by two sociology professors – Keith Robinson of the University of Texas in Austin and Angel L. Harris of Duke University in Durham, N.C. – suggests that the blade more often cuts in an unintended direction ("Parental Involvement Is Overrated" – New York Times Sunday Review, April 13, 2014). Their longitudinal study involved a survey of American families in the 1980’s to the 2000’s that looked at demographics, ethnicity, socioeconomic status, and levels of parental engagement (not just classroom volunteering) in relation to academic outcomes.

What they discovered was that in two groups divided by ethnicity and race but with similar levels of parental involvement, the children whose families valued education less highly did less well academically. The investigators also discovered that most forms of parental involvement "yielded no benefit to children’s test scores or grades regardless of racial or ethnic background or socioeconomic standing." In fact, when involvement did make a difference, it was more often negative.

Although most of us believe that regular reading to elementary school children has a positive effect, these authors found that while white and Hispanic children benefited, blacks did not. Obviously, parental involvement is a complex factor in children’s lives, and we must be careful about making assumptions before we make blanket recommendations. For example "consistent help with homework never improved test scores or grades," and in fact, regular help usually resulted in poorer performance.

However, parents can have a positive effect when they make it clear from the beginning that they value education and expect the child will go to college. Requesting a particular teacher helps as does discussing the child’s school activities at home. However, parents must expect that most of these discussions will be short.

I suspect that the professors would agree with my suggestion to parents that if they would like to help in the schools, they should volunteer in a classroom other than their own child’s, or even better, run the copier machine in the office or sweep out the equipment room in the gym.

Most of us cringe when we hear about extreme cases of helicopter parenting when parents rent apartments near campuses to be close to their college age children. But, few of us would have predicted the findings of this study that suggest parental involvement in younger children’s school lives is not only ineffective but often detrimental. As pediatricians, we can help parents do the counterintuitive thing and as these authors suggest, "set the stage and then get off."

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics including "How to Say No to Your Toddler." E-mail him at [email protected].

The story

FR was a 55-year-old woman who developed relatively acute and diffuse upper abdominal pain shortly after finishing dinner with friends at a local restaurant. Over the next 1-2 hours and after returning home, FR’s pain became most severe and was associated with nausea and emesis. FR contacted her daughter, who came over to assist. At approximately 10:30 p.m., FR called for an ambulance and was taken to the nearest emergency department.

On arrival at the ED, FR had a normal blood pressure and heart rate, but complained of 10/10 abdominal pain. An EKG was quickly performed and was normal. On examination, FR was noted by the ED physician as "uncooperative answering questions, rocking in bed moaning." The abdomen was documented as soft but diffusely tender to palpation in all four quadrants. A posteroanterior/lateral chest radiograph (CXR), full blood chemistries, and a complete blood cell count were obtained.

©Monkey Business Images/thinkstockphotos.com

The initial impression by the ED physician was biliary colic, and he also ordered a right upper quadrant ultrasound. In the meantime, FR received a "GI cocktail" (Mylanta, viscous lidocaine, and Donnatal) by mouth, along with intravenous morphine and Zofran. About 1 hour later, FR reported minimal improvement in her symptoms. The CXR, right upper quadrant ultrasound, Chem-12, lipase, and CBC all returned within normal limits.

At this point, the ED physician recommended discharge home with outpatient follow-up. The daughter, who had been with her mother all evening, became very upset and demanded that the patient be admitted because something was obviously wrong with her mother.

The ED physician called Dr. Hospitalist to admit FR for uncontrolled abdominal pain. An hour later, Dr. Hospitalist saw FR on the medical floor, by which time the daughter had left the hospital for home.

FR was lethargic from several doses of hydromorphone, but she was still complaining of severe abdominal pain. Dr. Hospitalist documented that FR had a history of hypertension, hyperlipidemia, anxiety, and depression, along with a gastric lap-band procedure 2 years ago for morbid obesity. FR’s abdomen was noted to be "reasonably soft" with hypoactive bowel sounds. The impression from Dr. Hospitalist was acute postprandial abdominal pain of unclear etiology. The plan included a routine GI consult, a routine plain film of the abdomen to look for evidence of gastric distention, keeping FR nothing per os (NPO), and continuing intravenous fluids and analgesia.

At 8:30 a.m., FR was found unresponsive and a Code Blue was called. Resuscitation efforts confirmed a profound acidemia (pH 6.55), and FR did not survive. FR was last seen by the nurses an hour earlier and had been documented as "sleeping." An autopsy was performed and discovered small bowel necrosis consistent with a small bowel volvulus.

Complaint

The daughter was shocked and upset over the sudden death of her mother. She felt that none of the medical providers took her mother’s complaints seriously because FR had a history of "anxiety." The daughter was particularly angry over the fact that the ED physician actually wanted to discharge FR in the presence of a lethal condition. She followed up with an attorney almost immediately, who had the case reviewed and subsequently filed a lawsuit.

The complaint alleged that the ED physician and Dr. Hospitalist both failed to appropriately image FR’s abdomen with either a plain abdominal radiograph and/or CT scan of the abdomen. The complaint further alleged that had they done so, the small bowel volvulus would have been discovered and successfully treated, preventing FR’s demise.

Scientific principles

Volvulus is a special form of mechanical intestinal obstruction. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery and often results in ischemia or even infarction.

When it occurs in adults, volvulus usually affects the sigmoid colon or the cecum. In contrast, small bowel volvulus is relatively rare. Plain radiography and CT of the abdomen are the most practical and useful diagnostic modalities.

All patients suspected of having complicated bowel obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based upon clinical and radiologic examination should be taken to the operating room for abdominal exploration. Failure to identify and treat small bowel volvulus in a timely manner can lead to catastrophic results.

Complaint rebuttal and discussion

The defense in this case focused on the rarity of this condition, along with the limited time window to successfully save FR’s life. The defense argued that while FR was in the window for diagnosis and successful treatment (i.e., 10:30 p.m. until 3 a.m.), all of FR’s vital signs were normal, and her abdominal exam was inconsistent with an acute abdomen.

The plaintiff countered that mechanical bowel obstruction (not necessarily a rare volvulus) was always in the differential diagnosis for acute and severe abdominal pain, and the failure to perform plain radiography of the abdomen was in and of itself negligent. Plaintiff experts opined that had the providers in this case performed plain radiography as the standard of care required, FR’s rare diagnosis would have been discovered, even if by "accident."

Conclusion

Dr. Hospitalist documented a desire to obtain a plain abdominal radiograph, but he ordered it routine and therefore it was never performed prior to FR’s death. Had Dr. Hospitalist obtained the film STAT, more likely than not the volvulus would have been identified well within the window to get FR a surgical consult and to the operating room for treatment.

This case is another example of what turned out to be an incomplete workup from the ED in the setting of "uncontrolled pain" (see previous column). Admission for "pain control" is a red flag for an underlying disorder that has been missed by the initial ED evaluation. In this case, the workup should have reasonably included a plain radiograph of the abdomen. This case was eventually settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at ehospitalistnews.com/Lessons.

The story

FR was a 55-year-old woman who developed relatively acute and diffuse upper abdominal pain shortly after finishing dinner with friends at a local restaurant. Over the next 1-2 hours and after returning home, FR’s pain became most severe and was associated with nausea and emesis. FR contacted her daughter, who came over to assist. At approximately 10:30 p.m., FR called for an ambulance and was taken to the nearest emergency department.

On arrival at the ED, FR had a normal blood pressure and heart rate, but complained of 10/10 abdominal pain. An EKG was quickly performed and was normal. On examination, FR was noted by the ED physician as "uncooperative answering questions, rocking in bed moaning." The abdomen was documented as soft but diffusely tender to palpation in all four quadrants. A posteroanterior/lateral chest radiograph (CXR), full blood chemistries, and a complete blood cell count were obtained.

©Monkey Business Images/thinkstockphotos.com

The initial impression by the ED physician was biliary colic, and he also ordered a right upper quadrant ultrasound. In the meantime, FR received a "GI cocktail" (Mylanta, viscous lidocaine, and Donnatal) by mouth, along with intravenous morphine and Zofran. About 1 hour later, FR reported minimal improvement in her symptoms. The CXR, right upper quadrant ultrasound, Chem-12, lipase, and CBC all returned within normal limits.

At this point, the ED physician recommended discharge home with outpatient follow-up. The daughter, who had been with her mother all evening, became very upset and demanded that the patient be admitted because something was obviously wrong with her mother.

The ED physician called Dr. Hospitalist to admit FR for uncontrolled abdominal pain. An hour later, Dr. Hospitalist saw FR on the medical floor, by which time the daughter had left the hospital for home.

FR was lethargic from several doses of hydromorphone, but she was still complaining of severe abdominal pain. Dr. Hospitalist documented that FR had a history of hypertension, hyperlipidemia, anxiety, and depression, along with a gastric lap-band procedure 2 years ago for morbid obesity. FR’s abdomen was noted to be "reasonably soft" with hypoactive bowel sounds. The impression from Dr. Hospitalist was acute postprandial abdominal pain of unclear etiology. The plan included a routine GI consult, a routine plain film of the abdomen to look for evidence of gastric distention, keeping FR nothing per os (NPO), and continuing intravenous fluids and analgesia.

At 8:30 a.m., FR was found unresponsive and a Code Blue was called. Resuscitation efforts confirmed a profound acidemia (pH 6.55), and FR did not survive. FR was last seen by the nurses an hour earlier and had been documented as "sleeping." An autopsy was performed and discovered small bowel necrosis consistent with a small bowel volvulus.

Complaint

The daughter was shocked and upset over the sudden death of her mother. She felt that none of the medical providers took her mother’s complaints seriously because FR had a history of "anxiety." The daughter was particularly angry over the fact that the ED physician actually wanted to discharge FR in the presence of a lethal condition. She followed up with an attorney almost immediately, who had the case reviewed and subsequently filed a lawsuit.

The complaint alleged that the ED physician and Dr. Hospitalist both failed to appropriately image FR’s abdomen with either a plain abdominal radiograph and/or CT scan of the abdomen. The complaint further alleged that had they done so, the small bowel volvulus would have been discovered and successfully treated, preventing FR’s demise.

Scientific principles

Volvulus is a special form of mechanical intestinal obstruction. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery and often results in ischemia or even infarction.

When it occurs in adults, volvulus usually affects the sigmoid colon or the cecum. In contrast, small bowel volvulus is relatively rare. Plain radiography and CT of the abdomen are the most practical and useful diagnostic modalities.

All patients suspected of having complicated bowel obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based upon clinical and radiologic examination should be taken to the operating room for abdominal exploration. Failure to identify and treat small bowel volvulus in a timely manner can lead to catastrophic results.

Complaint rebuttal and discussion

The defense in this case focused on the rarity of this condition, along with the limited time window to successfully save FR’s life. The defense argued that while FR was in the window for diagnosis and successful treatment (i.e., 10:30 p.m. until 3 a.m.), all of FR’s vital signs were normal, and her abdominal exam was inconsistent with an acute abdomen.

The plaintiff countered that mechanical bowel obstruction (not necessarily a rare volvulus) was always in the differential diagnosis for acute and severe abdominal pain, and the failure to perform plain radiography of the abdomen was in and of itself negligent. Plaintiff experts opined that had the providers in this case performed plain radiography as the standard of care required, FR’s rare diagnosis would have been discovered, even if by "accident."

Conclusion

Dr. Hospitalist documented a desire to obtain a plain abdominal radiograph, but he ordered it routine and therefore it was never performed prior to FR’s death. Had Dr. Hospitalist obtained the film STAT, more likely than not the volvulus would have been identified well within the window to get FR a surgical consult and to the operating room for treatment.

This case is another example of what turned out to be an incomplete workup from the ED in the setting of "uncontrolled pain" (see previous column). Admission for "pain control" is a red flag for an underlying disorder that has been missed by the initial ED evaluation. In this case, the workup should have reasonably included a plain radiograph of the abdomen. This case was eventually settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at ehospitalistnews.com/Lessons.

The story

FR was a 55-year-old woman who developed relatively acute and diffuse upper abdominal pain shortly after finishing dinner with friends at a local restaurant. Over the next 1-2 hours and after returning home, FR’s pain became most severe and was associated with nausea and emesis. FR contacted her daughter, who came over to assist. At approximately 10:30 p.m., FR called for an ambulance and was taken to the nearest emergency department.

On arrival at the ED, FR had a normal blood pressure and heart rate, but complained of 10/10 abdominal pain. An EKG was quickly performed and was normal. On examination, FR was noted by the ED physician as "uncooperative answering questions, rocking in bed moaning." The abdomen was documented as soft but diffusely tender to palpation in all four quadrants. A posteroanterior/lateral chest radiograph (CXR), full blood chemistries, and a complete blood cell count were obtained.

©Monkey Business Images/thinkstockphotos.com

The initial impression by the ED physician was biliary colic, and he also ordered a right upper quadrant ultrasound. In the meantime, FR received a "GI cocktail" (Mylanta, viscous lidocaine, and Donnatal) by mouth, along with intravenous morphine and Zofran. About 1 hour later, FR reported minimal improvement in her symptoms. The CXR, right upper quadrant ultrasound, Chem-12, lipase, and CBC all returned within normal limits.

At this point, the ED physician recommended discharge home with outpatient follow-up. The daughter, who had been with her mother all evening, became very upset and demanded that the patient be admitted because something was obviously wrong with her mother.

The ED physician called Dr. Hospitalist to admit FR for uncontrolled abdominal pain. An hour later, Dr. Hospitalist saw FR on the medical floor, by which time the daughter had left the hospital for home.

FR was lethargic from several doses of hydromorphone, but she was still complaining of severe abdominal pain. Dr. Hospitalist documented that FR had a history of hypertension, hyperlipidemia, anxiety, and depression, along with a gastric lap-band procedure 2 years ago for morbid obesity. FR’s abdomen was noted to be "reasonably soft" with hypoactive bowel sounds. The impression from Dr. Hospitalist was acute postprandial abdominal pain of unclear etiology. The plan included a routine GI consult, a routine plain film of the abdomen to look for evidence of gastric distention, keeping FR nothing per os (NPO), and continuing intravenous fluids and analgesia.

At 8:30 a.m., FR was found unresponsive and a Code Blue was called. Resuscitation efforts confirmed a profound acidemia (pH 6.55), and FR did not survive. FR was last seen by the nurses an hour earlier and had been documented as "sleeping." An autopsy was performed and discovered small bowel necrosis consistent with a small bowel volvulus.

Complaint

The daughter was shocked and upset over the sudden death of her mother. She felt that none of the medical providers took her mother’s complaints seriously because FR had a history of "anxiety." The daughter was particularly angry over the fact that the ED physician actually wanted to discharge FR in the presence of a lethal condition. She followed up with an attorney almost immediately, who had the case reviewed and subsequently filed a lawsuit.

The complaint alleged that the ED physician and Dr. Hospitalist both failed to appropriately image FR’s abdomen with either a plain abdominal radiograph and/or CT scan of the abdomen. The complaint further alleged that had they done so, the small bowel volvulus would have been discovered and successfully treated, preventing FR’s demise.

Scientific principles

Volvulus is a special form of mechanical intestinal obstruction. It results from abnormal twisting of a loop of bowel around the axis of its own mesentery and often results in ischemia or even infarction.

When it occurs in adults, volvulus usually affects the sigmoid colon or the cecum. In contrast, small bowel volvulus is relatively rare. Plain radiography and CT of the abdomen are the most practical and useful diagnostic modalities.

All patients suspected of having complicated bowel obstruction (complete obstruction, closed-loop obstruction, bowel ischemia, necrosis, or perforation) based upon clinical and radiologic examination should be taken to the operating room for abdominal exploration. Failure to identify and treat small bowel volvulus in a timely manner can lead to catastrophic results.

Complaint rebuttal and discussion

The defense in this case focused on the rarity of this condition, along with the limited time window to successfully save FR’s life. The defense argued that while FR was in the window for diagnosis and successful treatment (i.e., 10:30 p.m. until 3 a.m.), all of FR’s vital signs were normal, and her abdominal exam was inconsistent with an acute abdomen.

The plaintiff countered that mechanical bowel obstruction (not necessarily a rare volvulus) was always in the differential diagnosis for acute and severe abdominal pain, and the failure to perform plain radiography of the abdomen was in and of itself negligent. Plaintiff experts opined that had the providers in this case performed plain radiography as the standard of care required, FR’s rare diagnosis would have been discovered, even if by "accident."

Conclusion

Dr. Hospitalist documented a desire to obtain a plain abdominal radiograph, but he ordered it routine and therefore it was never performed prior to FR’s death. Had Dr. Hospitalist obtained the film STAT, more likely than not the volvulus would have been identified well within the window to get FR a surgical consult and to the operating room for treatment.

This case is another example of what turned out to be an incomplete workup from the ED in the setting of "uncontrolled pain" (see previous column). Admission for "pain control" is a red flag for an underlying disorder that has been missed by the initial ED evaluation. In this case, the workup should have reasonably included a plain radiograph of the abdomen. This case was eventually settled on behalf of the plaintiff for an undisclosed amount.

Dr. Michota is director of academic affairs in the hospital medicine department at the Cleveland Clinic and medical editor of Hospitalist News. He has been involved in peer review both within and outside the legal system. Read past columns at ehospitalistnews.com/Lessons.

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

QUESTION: The medical staff at the newly opened hospital is putting together a set of bylaws covering credentialing, peer review, and patient-care quality assurance. The doctors are mostly independent contractors and not hospital employees. The administration, obsessed with financial solvency, wishes to retain veto power over decisions affecting staff privileges. In potential disputes affecting the hospital and its medical staff, which of the following is true?

A. The Joint Commission subscribes to the view that hospital administration rather medical staff has overall authority over clinical privileges decisions.

B. Economic credentialing is universally regarded as unethical and illegal.

C. Medical bylaws are a contractual agreement.

D. A hospital can never make unilateral changes in the medical staff bylaws.

E. The medical staff is an integral part of the hospital’s organizational structure, with its powers wholly independent of the hospital’s governing board.

BEST ANSWER: A. Doctors with hospital privileges typically organize themselves into a formal medical staff, with its powers derived from the hospital’s governing board. Professional organizations such as the American Medical Association believe that the medical staff of a facility should be self governing, with its own enforceable set of bylaws. The general view is that these bylaws do not create a binding contractual agreement.

For example, when Dr. George T. O’Byrne sued Santa Monica–UCLA Medical Center where he held medical staff privileges, the California Court of Appeal ruled that the hospital’s fiduciary duty is to its shareholders and the public – but not to its physicians – and that the medical staff bylaws did not constitute a contract (OByrne v. Santa Monica-UCLA Medical Center, 114 Cal.Rptr.2d 575 [Cal. Ct. App. 2001]).

A similar situation appears to hold in Minnesota, where the medical staff accused Avera Marshall Regional Medical Center of unilateral credentialing and revision of the bylaws, and interference with quality assurance operations (Avera Marshall Medical Staff v. Avera Marshall Regional Medical Center, 836 N.W.2d 549 [Minn. Ct. App. 2013]). Both the trial court and the court of appeals have held that the medical staff lacked the legal capacity to bring a lawsuit and that the bylaws were not a contract (the final decision of the Minnesota Supreme Court is pending).

The Joint Commission’s view is that the hospital administration has the ultimate authority over clinical privileges of its medical staff, in support of the legal doctrine that a hospital can be held liable for the torts of its practitioners. This notion of corporate liability, which includes negligent credentialing, stemmed from the seminal Darling case (Darling v. Charleston Community Hospital, 211 N.E.2d 253 [Ill. 1965]) where the court held the hospital liable for failing to adequately review the qualifications and performance of a negligent medical staff member. Dr. Alexander, the doctor at issue, had applied a plaster cast too tightly, which caused the college football player to eventually lose his leg.

Other cases followed, including the infamous California case of Gonzales v. Nork, 573 P.2d 458 (Cal. 1978), in which a drug-abusing doctor misrepresented himself as being qualified to perform laminectomies. Even in jurisdictions such as Minnesota, which does not specifically recognize negligent credentialing as a legal cause of action, its supreme court has allowed this legal theory to go forward.

Two recurring issues tending to embroil hospital and staff in conflict are unilateral actions by a medical center and the use of economic credentialing.

The usual procedure for amending the bylaws is for the medical staff to initiate and approve changes before subjecting them for final endorsement by the hospital board. Thus, when a Florida hospital unilaterally refused to re-credential two qualified radiation oncologists because of its intention to exclusively contract with the University of Miami School of Medicine for all radiation oncology procedures, the jury found in favor of the aggrieved doctors, awarding them $2.5 million in lost profits and $20.25 million in punitive damages (Columbia/JFK Medical Center v. Spunberg, 784 So.2d 541 (Fla. App. Ct. 2001).

Likewise, a small Georgia hospital tried to close its cardiology department in order to enter into an exclusive contract with a separate group of cardiologists. The Georgia Court of Appeals held that a hospital could not deprive physicians of access to its facilities unless stated in the bylaws or specifically agreed to in an individual contract (Satilla Health Services v. Bell, 633 S.E.2d 575 [Ga. Ct. App. 2006]).

However, under some narrow circumstances, a hospital can act unilaterally, without medical staff agreement, especially where the bylaws are silent on the point. Illinois recently ruled that a medical center could, without physician assent, increase physician malpractice premium limits to $1,000,000 per occurrence and $3,000,000 aggregate for multiple occurrences (from $200,000 and $600,000, respectively). Its appellate court allowed the change, holding that physician enforcement of its bylaws were restricted only to matters of clinical competence (Fabrizio v. Provena United Samaritans, 857 N.E.2d 670 [Ill. S.Ct. 2006]).

And in Lo v. Provena Covenant Hospital, 796 N.E.2d 607 (Ill. App. Ct. 2003), a hospital unilaterally and summarily suspended a cardiovascular surgeon who allegedly had twice the national mortality rate. The medical staff leadership had not been responsive to the hospital’s concern of imminent danger to patients. The Illinois Appellate Court made the finding that in this "anomalous" case, the hospital’s actions were neither arbitrary, capricious, nor in violation of the bylaws.

A second area of conflict between doctors and hospitals is hospitals’ use of economic factors in credentialing, where financial factors are used to profile – and determine – a physician’s application for privileges.

For example, a staff gynecologist risked losing her 19-year membership at Baptist Health Medical Center in Little Rock, Ark., because her physician-husband owned an interest in a competing hospital specializing in spinal surgery. The case settled when the husband divested his competing ownership. In Arkansas, the courts have ruled that Baptist Health’s policy wherein a physician who holds a financial interest in a competing hospital is ineligible for privileges at any Baptist Health hospital is both unconscionable and illegal, and the hospital economic credentialing policy tortiously interfered with the physicians’ existing and prospective business relationships (Murphy v. Baptist Health, 373 S.W.3d 269 [Ark. 2010]).

But other jurisdictions have not adopted this view. The South Dakota Supreme Court has ruled that a hospital administration may refuse applicants to the medical staff based on economic criteria (

<cf number="\"2\"">’</cf>

Mahan v. Avera St. Lukes, 621 N.W.2d 150 [S.D. S.Ct. 2001]). The court questioned the legal right of certain members of the medical staff to open a competing ambulatory surgery center. In a subsequent case, the same court held that in the absence of specific prohibitions in the bylaws, a hospital could use economic credentialing in its staffing determinations.

Even for physicians with only an occasional hospital practice, the following pointers from the book "The Biggest Legal Mistakes Physicians Make and How to Avoid Them," edited by Steven Babitsky and James J. Mangraviti Jr., may prove useful:

1) Failing to practice in a collegial manner.

2) Impugning the quality of care of the hospital, nurses, and other physicians.

3) Not knowing the hospital’s policies and procedures.

4) Not involving consultants when the issue is out of one’s specialty.

5) Not accepting constructive criticism and suggestions.

6) Failing to seek approval before prescribing unorthodox drugs or treatment.

7) Failing to respond promptly to inquiries about care or behavior.

8) Failing to follow up on an agreement resolving an issue.

9) Acting as though the hospital is lucky to have such a physician.

10) Not calling a lawyer when necessary.

Dr. Tan is professor emeritus of medicine and former adjunct professor of law at the University of Hawaii. This article is meant to be educational and does not constitute medical, ethical, or legal advice. Some of the articles in this series are adapted from the author’s 2006 book, "Medical Malpractice: Understanding the Law, Managing the Risk," and his 2012 Halsbury treatise, "Medical Negligence and Professional Misconduct." For additional information, readers may contact the author at [email protected].

What’s your idea of adventure travel? Scuba-diving with sharks? Scaling glaciers? Child’s play. I am about to spend 2 weeks driving around the western United States with five kids. Are you not yet afraid? Three of them are teenagers. Still not afraid? We’re taking away their iPhones. Now tell me you don’t feel the cold sweat.

Jupiterimages

We’re not broaching any whining, either. After all, we’re renting an SUV large enough to be seen from the International Space Station. And there will be old-school entertainment: travel BINGO, Mad Libs, and I-swear-if-you-don’t-stop-fighting-I’m-leaving-you-both-here-in-the-desert-to-walk-home. Then, when we reach our destination, my wife and I will play who-can-finish-their-wine-first. Depending on how this trip goes, we may make it a tradition, but just in case, save me a spot in the shark cage.

Make it work

Okay, y’all, I’m calling a moratorium on Jenny McCarthy jokes. I know what you’re thinking: “But she’s comedy gold! What else are you going to make fun of?” There’s always gross stuff guaranteed to get a laugh like baby poop, spit-up, and drug reps, but that’s not the point. The point is that no one would listen to vapid celebrities spouting antivaccine rhetoric if they didn’t have the support of a couple of actual pediatricians (let’s call them “Dr. Rob” and “Dr. Kay”) who’ve made lucrative careers selling pseudoscientific, legitimate-sounding arguments with all the integrity of, well, baby poop.

I know these guys  are tempted to rest on their laurels, having done their fair share to ensure that the next generation of doctors gets firsthand experience of measles and whooping cough, but thanks to a new study, they’re going to have to step up their game.  In order to argue against vaccines, you need to convince people of two things that are patently false: that vaccines are somehow dangerous, and that vaccine-preventable diseases are somehow safe. Oh, and one more: that you are somehow credible.

In order to better define what we mean when we say that vaccines are “safe,” Margaret A. Maglione, MPP of the Rand Corporation evaluated 20,478 studies of vaccine side effects. I can only assume that Ms. Maglione has no hobbies. The results would surprise only those people who have shelled out good money for books full of bad science.

Let me sum up: Measles/mumps/rubella vaccine does not cause autism, but it can cause febrile seizures which, unlike measles, mumps, and rubella, are harmless. (“Dr. Kay” doesn’t think measles is so bad because, you know, since no one he knows has died of it yet.) Varicella vaccine can cause problems for immunocompromised patients, which is why we don’t give it to immunocompromised patients. Rotavirus vaccine may cause very rare cases of intussusception, which must be weighed against its ability to prevent nearly 70,000 hospitalizations and 60 deaths a year in the U.S. alone.

Of course, I don’t think for a minute that solid science will cut into anyone’s book sales or the growing rates of preventable life-threatening diseases. If we’ve learned one thing from recent history, it’s that facts are never a barrier when people have a vested emotional or financial interest in ignoring them. After all, have you ever seen a baby run out of poop?

Kids' size

There are some experiences that really should wait for adulthood to be fully enjoyed: drinking champagne, gambling in Las Vegas, standing in line at the DMV. To this list I propose we add looking critically at your body. Kids should still just be amazed to have a belly button, not looking in the mirror and wondering how they can lose some of that applesauce weight. A new study out of Australia, however, suggests that body dissatisfaction starts at an alarmingly young age: 8-9 years old. And that’s only because that’s the age group the authors studied. For all we know, there are infants out there comparing themselves to Cabbage Patch Kids and thinking, “I wish my cheeks weren’t so chubby...”

The study, headed by Dr. Ben Edwards of the Australian Institute of Family Studies, tracked more than 4,000 children from age 8 to age 11 years, comparing their perceptions of their bodies to their actual sizes. More than half the children said they desired a body size that was slightly thinner than average, making me wonder what sort of scrawny superheroes they show on Australian television. By age 11, 61% of boys and 56% of girls had tried to do something to manage their weight, with the most effective intervention being “not moving to America.”

Just like adults, kids who were unhappy with their bodies also had more problems being social and enjoying exercise. I think it’s tragic that children this young are already developing body issues, and in a country with distractions as amazing as actual kangaroos! And of course it won’t be long before the hucksters exploit this market: Who wants a Garcinia gummy?!

Framed

In school, kids used to call me “four-eyes.” Then I’d  explain calmly that I didn’t actually have four eyes, it was just that due to the high refractive index of my glasses, light traveling at certain angles would produce duplicate images, which I’d then go on to demonstrate with a simple diagram and a protractor, which did nothing to stop the name-calling. Now a group of ophthalmologists from Germany have used science and technology to prove that the stereotype of the squinting intellectual is based in truth. I hate stereotypes, and anyway, could anything be more German?

The study found a strong correlation between years spent in school and myopia, bolstering theories that staying indoors and staring at books actually contribute to the changes in eye structure that cause nearsightedness. The authors suggest that if kids spend more time outdoors, fewer of them will need glasses. It’s already too late to save two of our children from my fate, but I think taking away the iPhones is a good start, and if that doesn’t work, there’s always that walk in the desert.

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

What’s your idea of adventure travel? Scuba-diving with sharks? Scaling glaciers? Child’s play. I am about to spend 2 weeks driving around the western United States with five kids. Are you not yet afraid? Three of them are teenagers. Still not afraid? We’re taking away their iPhones. Now tell me you don’t feel the cold sweat.

Jupiterimages

We’re not broaching any whining, either. After all, we’re renting an SUV large enough to be seen from the International Space Station. And there will be old-school entertainment: travel BINGO, Mad Libs, and I-swear-if-you-don’t-stop-fighting-I’m-leaving-you-both-here-in-the-desert-to-walk-home. Then, when we reach our destination, my wife and I will play who-can-finish-their-wine-first. Depending on how this trip goes, we may make it a tradition, but just in case, save me a spot in the shark cage.

Make it work

Okay, y’all, I’m calling a moratorium on Jenny McCarthy jokes. I know what you’re thinking: “But she’s comedy gold! What else are you going to make fun of?” There’s always gross stuff guaranteed to get a laugh like baby poop, spit-up, and drug reps, but that’s not the point. The point is that no one would listen to vapid celebrities spouting antivaccine rhetoric if they didn’t have the support of a couple of actual pediatricians (let’s call them “Dr. Rob” and “Dr. Kay”) who’ve made lucrative careers selling pseudoscientific, legitimate-sounding arguments with all the integrity of, well, baby poop.

I know these guys  are tempted to rest on their laurels, having done their fair share to ensure that the next generation of doctors gets firsthand experience of measles and whooping cough, but thanks to a new study, they’re going to have to step up their game.  In order to argue against vaccines, you need to convince people of two things that are patently false: that vaccines are somehow dangerous, and that vaccine-preventable diseases are somehow safe. Oh, and one more: that you are somehow credible.

In order to better define what we mean when we say that vaccines are “safe,” Margaret A. Maglione, MPP of the Rand Corporation evaluated 20,478 studies of vaccine side effects. I can only assume that Ms. Maglione has no hobbies. The results would surprise only those people who have shelled out good money for books full of bad science.

Let me sum up: Measles/mumps/rubella vaccine does not cause autism, but it can cause febrile seizures which, unlike measles, mumps, and rubella, are harmless. (“Dr. Kay” doesn’t think measles is so bad because, you know, since no one he knows has died of it yet.) Varicella vaccine can cause problems for immunocompromised patients, which is why we don’t give it to immunocompromised patients. Rotavirus vaccine may cause very rare cases of intussusception, which must be weighed against its ability to prevent nearly 70,000 hospitalizations and 60 deaths a year in the U.S. alone.

Of course, I don’t think for a minute that solid science will cut into anyone’s book sales or the growing rates of preventable life-threatening diseases. If we’ve learned one thing from recent history, it’s that facts are never a barrier when people have a vested emotional or financial interest in ignoring them. After all, have you ever seen a baby run out of poop?

Kids' size

There are some experiences that really should wait for adulthood to be fully enjoyed: drinking champagne, gambling in Las Vegas, standing in line at the DMV. To this list I propose we add looking critically at your body. Kids should still just be amazed to have a belly button, not looking in the mirror and wondering how they can lose some of that applesauce weight. A new study out of Australia, however, suggests that body dissatisfaction starts at an alarmingly young age: 8-9 years old. And that’s only because that’s the age group the authors studied. For all we know, there are infants out there comparing themselves to Cabbage Patch Kids and thinking, “I wish my cheeks weren’t so chubby...”

The study, headed by Dr. Ben Edwards of the Australian Institute of Family Studies, tracked more than 4,000 children from age 8 to age 11 years, comparing their perceptions of their bodies to their actual sizes. More than half the children said they desired a body size that was slightly thinner than average, making me wonder what sort of scrawny superheroes they show on Australian television. By age 11, 61% of boys and 56% of girls had tried to do something to manage their weight, with the most effective intervention being “not moving to America.”

Just like adults, kids who were unhappy with their bodies also had more problems being social and enjoying exercise. I think it’s tragic that children this young are already developing body issues, and in a country with distractions as amazing as actual kangaroos! And of course it won’t be long before the hucksters exploit this market: Who wants a Garcinia gummy?!

Framed

In school, kids used to call me “four-eyes.” Then I’d  explain calmly that I didn’t actually have four eyes, it was just that due to the high refractive index of my glasses, light traveling at certain angles would produce duplicate images, which I’d then go on to demonstrate with a simple diagram and a protractor, which did nothing to stop the name-calling. Now a group of ophthalmologists from Germany have used science and technology to prove that the stereotype of the squinting intellectual is based in truth. I hate stereotypes, and anyway, could anything be more German?

The study found a strong correlation between years spent in school and myopia, bolstering theories that staying indoors and staring at books actually contribute to the changes in eye structure that cause nearsightedness. The authors suggest that if kids spend more time outdoors, fewer of them will need glasses. It’s already too late to save two of our children from my fate, but I think taking away the iPhones is a good start, and if that doesn’t work, there’s always that walk in the desert.

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

What’s your idea of adventure travel? Scuba-diving with sharks? Scaling glaciers? Child’s play. I am about to spend 2 weeks driving around the western United States with five kids. Are you not yet afraid? Three of them are teenagers. Still not afraid? We’re taking away their iPhones. Now tell me you don’t feel the cold sweat.

Jupiterimages

We’re not broaching any whining, either. After all, we’re renting an SUV large enough to be seen from the International Space Station. And there will be old-school entertainment: travel BINGO, Mad Libs, and I-swear-if-you-don’t-stop-fighting-I’m-leaving-you-both-here-in-the-desert-to-walk-home. Then, when we reach our destination, my wife and I will play who-can-finish-their-wine-first. Depending on how this trip goes, we may make it a tradition, but just in case, save me a spot in the shark cage.

Make it work

Okay, y’all, I’m calling a moratorium on Jenny McCarthy jokes. I know what you’re thinking: “But she’s comedy gold! What else are you going to make fun of?” There’s always gross stuff guaranteed to get a laugh like baby poop, spit-up, and drug reps, but that’s not the point. The point is that no one would listen to vapid celebrities spouting antivaccine rhetoric if they didn’t have the support of a couple of actual pediatricians (let’s call them “Dr. Rob” and “Dr. Kay”) who’ve made lucrative careers selling pseudoscientific, legitimate-sounding arguments with all the integrity of, well, baby poop.

I know these guys  are tempted to rest on their laurels, having done their fair share to ensure that the next generation of doctors gets firsthand experience of measles and whooping cough, but thanks to a new study, they’re going to have to step up their game.  In order to argue against vaccines, you need to convince people of two things that are patently false: that vaccines are somehow dangerous, and that vaccine-preventable diseases are somehow safe. Oh, and one more: that you are somehow credible.

In order to better define what we mean when we say that vaccines are “safe,” Margaret A. Maglione, MPP of the Rand Corporation evaluated 20,478 studies of vaccine side effects. I can only assume that Ms. Maglione has no hobbies. The results would surprise only those people who have shelled out good money for books full of bad science.

Let me sum up: Measles/mumps/rubella vaccine does not cause autism, but it can cause febrile seizures which, unlike measles, mumps, and rubella, are harmless. (“Dr. Kay” doesn’t think measles is so bad because, you know, since no one he knows has died of it yet.) Varicella vaccine can cause problems for immunocompromised patients, which is why we don’t give it to immunocompromised patients. Rotavirus vaccine may cause very rare cases of intussusception, which must be weighed against its ability to prevent nearly 70,000 hospitalizations and 60 deaths a year in the U.S. alone.

Of course, I don’t think for a minute that solid science will cut into anyone’s book sales or the growing rates of preventable life-threatening diseases. If we’ve learned one thing from recent history, it’s that facts are never a barrier when people have a vested emotional or financial interest in ignoring them. After all, have you ever seen a baby run out of poop?

Kids' size

There are some experiences that really should wait for adulthood to be fully enjoyed: drinking champagne, gambling in Las Vegas, standing in line at the DMV. To this list I propose we add looking critically at your body. Kids should still just be amazed to have a belly button, not looking in the mirror and wondering how they can lose some of that applesauce weight. A new study out of Australia, however, suggests that body dissatisfaction starts at an alarmingly young age: 8-9 years old. And that’s only because that’s the age group the authors studied. For all we know, there are infants out there comparing themselves to Cabbage Patch Kids and thinking, “I wish my cheeks weren’t so chubby...”

The study, headed by Dr. Ben Edwards of the Australian Institute of Family Studies, tracked more than 4,000 children from age 8 to age 11 years, comparing their perceptions of their bodies to their actual sizes. More than half the children said they desired a body size that was slightly thinner than average, making me wonder what sort of scrawny superheroes they show on Australian television. By age 11, 61% of boys and 56% of girls had tried to do something to manage their weight, with the most effective intervention being “not moving to America.”

Just like adults, kids who were unhappy with their bodies also had more problems being social and enjoying exercise. I think it’s tragic that children this young are already developing body issues, and in a country with distractions as amazing as actual kangaroos! And of course it won’t be long before the hucksters exploit this market: Who wants a Garcinia gummy?!

Framed

In school, kids used to call me “four-eyes.” Then I’d  explain calmly that I didn’t actually have four eyes, it was just that due to the high refractive index of my glasses, light traveling at certain angles would produce duplicate images, which I’d then go on to demonstrate with a simple diagram and a protractor, which did nothing to stop the name-calling. Now a group of ophthalmologists from Germany have used science and technology to prove that the stereotype of the squinting intellectual is based in truth. I hate stereotypes, and anyway, could anything be more German?

The study found a strong correlation between years spent in school and myopia, bolstering theories that staying indoors and staring at books actually contribute to the changes in eye structure that cause nearsightedness. The authors suggest that if kids spend more time outdoors, fewer of them will need glasses. It’s already too late to save two of our children from my fate, but I think taking away the iPhones is a good start, and if that doesn’t work, there’s always that walk in the desert.

David L. Hill, M.D., FAAP, is the author of Dad to Dad: Parenting Like a Pro (AAP Publishing, 2012). He is also vice president of Cape Fear Pediatrics in Wilmington, N.C., and  adjunct assistant professor of pediatrics at the University of North Carolina at Chapel Hill. He serves as Program Director for the AAP Council on Communications and Media and as an executive committee member of the North Carolina Pediatric Society. He has recorded commentaries for NPR's All Things Considered and provided content for various print, television, and Internet outlets.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.

In recent months I’ve participated in several system-level efforts to reduce avoidable readmissions, with considerable focus placed upon handoff communication. Over the arc of my career, handoff communication has become increasingly important as inpatient care becomes more fragmented, resulting in several national initiatives. To date, there has been no such effort placed upon communication during the hospitalization.

The Joint Commission has estimated that up to 70% of sentinel events have poor interprofessional communication as a contributing factor. HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) domains emphasize communication between physicians, nurses, and patients. Patient care suffers when health care teams do not communicate effectively, and patient satisfaction follows suit.

A few recent examples from the palliative care service:

• A 54-year-old male hospitalized with cord compression secondary to malignancy and infection was evaluated by five different surgical subspecialists over a 6-day period. An additional 4 days passed before the surgeons were able to speak and agree upon a plan.

• A 16-year-old girl with epilepsy was admitted after elective orthognathic surgery. It took 2 weeks of effort (preoperatively) on the part of her parents to ensure that the surgeon and neurologist developed a plan for antiepileptic therapy while the patient was NPO for 5 days.

• An ethics case conference was called to discuss the case of a 62-year-old woman with cirrhosis and sepsis. Two of the providers involved disagreed over the patient’s prognosis and whether enteral nutrition should be continued. At the case conference, the providers were able to discuss the case face to face, and the issue was resolved. Prior to the meeting, they had not discussed the case except through progress notes.

It is curious that, in the age of nearly continuous communication via text, e-mail, Internet, and even wearable devices, we physicians have such difficulty having a quick conversation about a patient over the phone. How can this be? In my practice, I have almost no problem reaching my colleagues when there is an emergency. In the nonemergent situation, however, it is more complicated. I don’t want to pull my colleague away from a patient (whether office- or hospital-based) for an important, but nonurgent matter. For my hospital-based colleagues, there is no office staff with whom to leave a message.

As we are all being asked to see more patients, the time for reviewing charts and returning calls is progressively reduced. Standard text messaging is not HIPAA compliant; however, there are fee-based HIPAA-compliant text applications. Our local county medical society offers this as a benefit of membership, but to date only a minority of my colleagues are users.

As we move toward more team-based care and pay for performance, it is imperative for physicians to agree upon standards for communication and for health care systems to invest in infrastructure to facilitate effective communication and collaboration. If we fail to do so, it is likely that external forces (third-party payers, regulatory agencies, etc.) will impose their own standards, without our input.

Dr. Fredholm and colleague Dr. Stephen Bekanich are codirectors of Seton Palliative Care, part of the University of Texas Southwestern Residency Programs in Austin. They alternate contributions to the monthly Palliatively Speaking blog.