Avoiding the Slippery Slope

slippery slopeBy Debra Grossbaum

 As a general rule, most doctors are rule followers. They are typically aware of the basis for structured parameters and are willing to take the steps necessary to do things properly. However, doctors are also generally pressed for time, resources, and compensation.

These deficits may lead even the best physicians to succumb to shortcuts, some of which may seem quite harmless, but which may lead to unforeseen and quite consequential outcomes.

Technology

One area of potential risk is in the area of technology. While we now revel in this age of immediate communication, we may not be fully focused on the potential pitfalls of computer and cellphone communications.

For example, a physician was trying to wrap up the last few patient calls of the day when he chose to use his cellphone instead of his office line, so he could talk while heading out of the office. He didn’t consider that by calling on his cell, he was disclosing his personal number to several patients. At least one patient took this as a suggestion that the call was more of a personal nature than was intended, and another later used the number to contact the doctor for inappropriate questions at inappropriate times.

While such calls would otherwise be vetted by a receptionist, this physician now found himself in quite an uncomfortable position that was clearly unintended. Similarly, physicians may use personal email addresses to zip out quick responses when pressed for time.

However, by doing so, not only is the patient receiving the doctor’s personal contact information, but there is also a likelihood that the personal email account lacks the type of encryption required for physician/patient communications.

While the communication may seem benign, just the fact that a patient has come to you as a physician may be sufficiently protected information as to constitute a confidentiality violation if disclosed without proper encryption.

Collegial Consults

Another prevalent, but dangerous, dynamic is the proverbial “curbside consult.” Most physicians acknowledge that care should be provided in the context of a formal doctor/patient relationship, with an exam and patient record.

Many doctors also feel justified in seeking a quick prescription from a friend when pressed for time, especially when the medication is common, or the asking physician appears confident that it is an appropriate use.

However, the risks here may be much more extensive than considered. Ultimately, the physician who is providing the prescription will be held responsible for the care, so if the colleague is abusing the medication, or has a negative drug reaction, the well-meaning colleague may be liable.

Also, sometimes the medication or the casual consult can interfere with necessary medical care. One physician casually and regularly provided a colleague with medication to treat what was assumed to be a migraine headache.

Ultimately it was learned that the physician-patient was suffering from symptoms of a brain tumor. The tumor went undetected for the duration of the time that the colleague provided the analgesic without conducting a complete exam.

Prescriptive Practice

Patients can be very persuasive when it comes to seeking medications. They may describe pain, psychological distress, insomnia, or a variety of other symptoms that are hard to quantify, confirm, or refute. With little time, and an anxious patient, it can seem easiest to just write a quick prescription.

While medication is often necessary, it is important to take the time to use all of the resources available to support the necessity of a prescription, especially for substances that are potentially abused. Even when time is short and pressure is on, it is essential to check the state’s online Prescription Monitoring Program. This can provide critical information as to whether the patient has already obtained medications elsewhere.

Also, whenever possible, gather objective data to confirm or rule out a diagnosis before prescribing. This might include MRI, comprehensive physical exam, or even an independent pain consult. While patients might balk at these extra steps, taking them at the front end may preclude a cascade of subsequent consequences.

We are all faced with daily demands competing for our time, and we have to make quick decisions to best allocate our time and resources. When doing so, as a physician, it is helpful to be mindful of the importance of protocol and the purpose of such protocol before agreeing to take steps, even baby steps, away from the rulebook. It is well worth the time.


Debra Grossbaum is General Counsel for Physician Health Services. This article first appeared in the May  2014 edition of the Massachusetts Medical Society publication Vital Signs.

Physician Health Services, Inc., is a non-profit corporation founded by the Massachusetts Medical Society. PHS  provides confidential consultation and support to physicians, residents, and medical students facing concerns related to alcoholism, substance abuse, behavioral or mental health issues, or physical illness. PHS also provides a safe environment where physicians can talk to other physicians about the stress and demands of modern medical practices. For more information, visit the PHS website or call PHS at (781) 434-7404.

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