When Physicians, Nonphysicians Disagree on Patient Care

I received an urgent call recently from a diabetes educator. Apparently, she had just seen a patient with very poorly controlled diabetes. His blood sugar was almost 400 (normal being around 100), he was a little dehydrated, his hemoglobin A1c (test of diabetic control) was too high for the lab to measure - "greater than 17" was all they could say, normal being no more than 5.6. For the unfamiliar, suffice it to say, he was in bad shape, and in danger of serious complications in the near future.

Now I wasn’t called for medical advice per se. I was called because she wanted to know what her legal and moral obligations were and where her limits were, because, allegedly, she had called the patient’s physician to ask for a prescription for insulin and she was told that the physician did not want to start the patient on insulin. She stressed that this was the appropriate management at this time, and was told that the patient would be referred to an endocrinologist. As anyone who regularly reads my blog will know, any patient that is referred to an endocrinologist in our area is likely to have a three-month to six-month wait. This patient did not have the luxury of waiting that long.

The educator had made the correct assessment and her plan was sound, but of course, she can’t write prescriptions. She was very concerned about this patient and quite upset with the doctor. She even used "the M word (malpractice)." She wondered if the patient needed to go to ER, but sadly, that would not have guaranteed the appropriate management either. In the end, I told her to tell the patient to come see me on a Monday. I squeezed him in at a time I do not normally see patients.

So we resolved that problem; or at least the problem of what to do with that particular patient. But the bigger question remains: What is the legal responsibility of healthcare professionals who are unable to officially make clinical decisions, when the person who can make that decision refuses to do so? And what course of action can one take?

For example, in the hospital, if a nurse thinks a patient needs a CT scan because she thinks the patient is having a stroke, she can’t order one until she gets an order for a doctor. What if the doctor (who probably isn’t present at the time) says it’s unnecessary?

Now don’t get me wrong. I certainly don’t want people who are not properly trained to make decisions that are beyond their scope. I don’t even want other doctors touching the meds I prescribe. But what does one do when they feel very strongly that a healthcare professional is not doing what is in the patient’s best interest, or worse is putting the patient at serious risk? They can’t all call another doctor for help. The only reason I got involved at all is because I am director of a diabetes education center. Should they tell the patient to get another doctor?

The healthcare community needs to work together to help patients. When there is a conflict within the team, there needs to be a way to arbitrate to find the best solution for the patient.