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    "When many cures are offered for a disease, it means the disease is not curable" -Anton Chekhov

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    Tuesday, June 08, 2004

    What Color Dress am I Wearing? The hazards of telephone medicine are legion, but still many patients expect us to make a diagnosis and treatment recommendations over the phone. I've even heard fellow physicians justify telephone medicine by quoting the old dictum that the history is the most important part of making a diagnosis. But you can't do away with the physical exam, as one Alaskan doctor tried to tell a patient, unsuccessfully. After she ignored his advice to let him examine her, she became critically ill and later sued:

    In this case, Marsingill, who had abdominal surgery several months earlier, called Dr. O'Malley at night complaining of pain, bloating and an inability to burp.

    He told her he couldn't evaluate her over the phone, and he didn't give her an opinion about what might be causing her symptoms, according to court records. Instead, Dr. O'Malley told Marsingill that he would meet her at the emergency department.

    She asked what they would do there, and he told her doctors would likely insert a nasogastric tube. Before hanging up the phone, Marsingill told Dr. O'Malley that she wasn't going to go to the hospital because she was feeling better and that she believed she could burp.

    Later that night, she passed out and went to the hospital by ambulance. She had intestinal blockage and went into shock, according to court records. Brain damage and partial paralysis followed.

    She lost - twice - but plans to appeal yet again. The case has made all Alaskan doctors shy not only about giving advice over the phone, but about talking to patients over the phone at all. Instead, they tell their patients to go to the ER after hours if they have a problem. They just can't take the risk:

    If Dr. O'Malley had lost the lawsuit, it could have cost him $7 million to $10 million. That's far more than his medical liability insurance would have covered.

    We often hear that lack of insurance coverage is the primary driver of emergency room overcrowding, but I would submit that it's really fear of litigation. When I think of the people I've sent to the ER after hours, the majority of them probably could have waited until the next day, but I'm apt to err on the side of caution. If there's the least bit of resistance on the part of the patient to a "take an aspirin and call the office in the morning" approach, I tell them to go to the ER. Or if it's a symptom that has the remotest chance of being serious - abdominal pain, chest pain, shortness of breath (even when they don't sound short of breath on the phone or the history is a rather weak one), I tell them to go to the ER. I'm not willing to take the chance of a multi-million dollar lawsuit. And I suspect I'm not alone. In fact, I know it. The doctors I share call with are the same way.

    posted by Sydney on 6/08/2004 08:11:00 AM 0 comments


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