The Patient-Physician Relationship: When Does it Start?

When does the patient-physician relationship start? And how far does the physician's responsibility go until the patient is seen?

I recently received a call from one of my patients. She was calling in behalf of her 90-year-old mother who is not a patient of mine. She wanted her seen ASAP because her blood sugar was over 500. My staff told her (based on directions I had given them previously) that she had to go the ER. The patient insisted that she needed an appointment to see me. I told my staff to tell her that there was nothing I could do for her in the office, that it would just delay her care, and that she needed to go to the hospital.

Next day - daughter calls again. Mom is still home, blood sugars are still high. I took the call and told her that this was an emergency, that her mother needed insulin and intravenous fluid, and that she needed to take her to the hospital. Eight hours later, I get the call from the ER - she finally made her way there. Her blood sugar was better, they had given her some IV fluid, and they wanted to send her home. I said, "On what?" She needed to take insulin at home and someone needed to teach her. Of course, this transpired on a Friday evening, so there was no diabetes educator, and a nurse would have to instruct her, and they don't do that in the ER. I understand that in this healthcare economy they needed justification to admit her, but I figured dehydration and severe hyperglycemia in the elderly? Come on, that's got to buy her at least a day.

An hour later, I get the call from the admitting doctor. He wants to send her home. We go through this same conversation. If she could be educated on self-administration of insulin in the ER, then fine, they could send her home, but I did not think this was wise.

On Saturday morning, I get the call from her nurse (yes, she got admitted). She wanted to know what to do with her insulin doses. I told her that despite the six phone calls that had taken place in last 36 hours, I had not seen the patient yet and I did not know how much insulin she required. Half an hour later, I get a call from the physician who was doing rounds that morning, wanting to know if she could send her home. Oy! I said I would be there in 20 minutes and that I would call her once I knew. Once I met her, I realized this was actually going to be more complicated, because her vision, dexterity, and memory made it impossible to do this on her own. So arrangements had to be made for someone else to administer her insulin for her at home.

So back to my questions. From the get-go, I knew this was an emergency and I made my recommendations. Those recommendations were initially dismissed and her condition could have significantly worsened had they not been heeded the next day. And I know that physicians call in orders to hospitals without seeing patients and call in prescriptions for patients they don't know if they are covering for another doctor, but there are certain decisions that just can't be made without speaking to and examining a patient. What if I had said to the ER doc or her admitting physician, "Well OK, if you think she's OK to go, send her home"? She would have ended up right back in that ER. And we all would have been responsible for that.