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-   -   Abuse of curbside consultation (http://www.behavior.net/bolforums/showthread.php?t=2168)

moviedoc September 28th, 2009 04:33 PM

Abuse of curbside consultation
 
An attorney asked me whether I would be willing to examine the client's spouse for a dissolution case. I agreed. The attorney planned to file a motion.

A few weeks later a prominent physician approached me in the doctor's lounge of the hospital where I belong to the staff and asked whether I do expert witness work in divorce cases. I said I do not do parenting evals, but occasionally opine on other matters, and described the question posed by the attorney as described above.

After a few more weeks the attorney calls again to tell me that the physician, who apparently treats the individual I was to have examined described our conversation to the parenting evaluator.

My question: Assuming the physician knew that I was asked to get involved in the case and was attempting to glean information that might be helpful to the patient's case is there an ethical or professional conduct problem with 1) stepping outside the usual role of a physician, and potentially interfering with the legal process, or 2) using deception in a setting where physicians should be able to speak freely, at least without identification of the patient, about cases?

William Reid October 7th, 2009 10:22 AM

Re: Abuse of curbside consultation
 
I wonder whether or not it was advisable to "describe the question posed by the attorney . . . above" to a colleague in the doctor's lounge, particularly if you knew the lawyer was from the same community as the doctor. Based on what you wrote, I don't see anything wrong with the doctor's query (he appears not to have been the one who revealed potentially-sensitive information, though I have almost no information about that). I'm a bit concerned about what you may have told him.

Second, is it possible that the doctor didn't know of your involvement and was merely trying to locate someone to whom he could refer the lawyer? And thus might logically offer your name to the attorney as a potential expert and let the lawyer take it from there? If so, then it would seem to be a reasonable effort to help his patient (and not "potentially interfering with the legal process"). (Note that we psychiatrists and other mental health professionals are -- and should be -- cautious about getting involved in patients' lives outside the treatment; however, other kinds of physicians can often do so without those dreaded "countertransference" and "treatment contamination" issues.)

I don't see, in what you wrote, any evidence of "deception," except for your thought that he might have known you were involved in the case. That may or may not be true, which is another reason to be careful about discussing cases -- even without names -- with colleagues.

Finally, I don't agree that a doctor's lounge should somehow be defined as a good place to "speak freely . . . about cases" like this. If two clinicians have a genuine clinical or educational reason to discuss a case (clinical or forensic, while considering confidentiality), that's fine, but I'm not sure what went on here, and I don't see a significant difference between the doctor's lounge and any other setting with regard to "speaking freely."

Maybe some clarification or additional information would help frame the issue for comment (but please don't be too verbose: we aren't going to solve the problems of the universe here -- not this week, at least :)).

WHR

moviedoc October 7th, 2009 11:00 AM

Re: Abuse of curbside consultation
 
Anything is possible but I have reason to believe the doctor knew of my involvement already, and was fishing, or what was the doctor doing?

To me the question of what it's OK to talk about in the doctor's lounge is on a continuum of what we can talk about in a blog or even a print publication. Assuming there is NO mention of name or other unique identifier, should we be able to say, "I was asked to testify in a malpractice case." (Very general.) or "I was asked to opine as to whether a party to a divorce might be diagnosed with gambling addiction." (still pretty general). The more specific the info revealed the more likely someone can identify the case. And the more public the forum, the less specific we can be.

You also raise the question of "community." In this case the attorney practices in another city about 30 miles away. Perhaps we should always assume we're in one big community.

Another way to look at this is that the fact that my answer might have been inappropriate does not make the quesiton posed OK.

A bit of a tangent again, but we are told to either get consent from the pt or make sure the case cannot be indentified when we publish case descriptions. I don't believe it is ethical to ask for consent, because the pt. might not feel free to refuse, wanting to avoid offending the doc. (No reference to transfer is needed.) That leaves us wondering how general we need to make the case for it to be OK, or, what I prefer, to fictionalize the case and say so. Over a year ago several prominent NYC psychiatrists described several cases in what I would think would be identifiable detail in the NY Times. There was no indication the cases were made up, and the NY Times is known for verification of such information. Was that unethical?

Thanks Bill.

William Reid October 7th, 2009 11:34 AM

Re: Abuse of curbside consultation
 
Setting aside the philosophical items (which others are welcome to address), I still don't see anything wrong with the question the doctor asked you, which was limited to (as you related it in your post): "Do you do expert witness work in divorce cases?" If the doctor was "fishing" (and he did apparently end up talking with the lawyer) then that may be discussible, but I'm not willing to pass judgement on him or his motives without a lot more information from either him or the lawyer (unlikely, I suppose).

Thirty miles away can be pretty close in terms of mentioning potentially identifying information (though I'm not saying you did so).

Let's hear from other readers --

WHR

Da Friendly Puter Tech October 7th, 2009 04:51 PM

Re: Abuse of curbside consultation
 
Ai, Ai, Ai, Discussing cases in the lounge. That is just a bit too nonchalant with sensitive information for my taste. You are not discussing cows - you are discussing humans.

There is always a chance that one of the doctors or other professionals in the lounge knows the patient in question. Then it is an all out HIPPA breach if that happens.

No way - doctors freely discussing cases in the lounge is wrong. Clinicians discussing patients with other clinicians in a controlled setting, and with the express understanding that if one clinician in the exchange speaks up should they know the patient is a different thing. This should also only be done if the clinician have a legitimate reason to seek the counsel of a colleague.


Da Friendly Puter Tech

moviedoc October 7th, 2009 05:16 PM

Re: Abuse of curbside consultation
 
Puter Tech

First, this was not my patient. It was the other docor's pt, but the other doc did not reveal anything to me.

Second, I am not a covered entity under HIPAA, because I do not bill electronically (Go to behavenet dot com and look for my blog post Nice to be N.a.C.E.). The other doc probably is. Even if I were a covered entity, it would only be a breach if the "patient" could be identified. And I could argue that I didn't release info about the non-patient anyway.

The lounge setting is a bit of a red herring here.

I do like that you said, "This should also only be done if the clinician [has] a legitimate reason to seek the counsel of a colleague. "

My position is that the doc who approached me did NOT have a legitimate reason to approach me, but did so under false pretenses.

I find it most interesting how strongly you and Dr. R feel about discussing cases in the lunch room/lounge. I wonder whether you have spent time in one recently. At our hospital I believe the medical staff actually encourages discussion of cases in the lounge as improving quality of care. We rarely identify the patients, although often the docs are already working as a team to care for the patient. I would be very surprised if this is not standard practice in most hospitals.

Another reality is that 90% of the time that I call another physician to coordinate care the other physician expresses no need to get authorization from the pt.

Thanks for jumping in.

Da Friendly Puter Tech October 9th, 2009 09:33 PM

Re: Abuse of curbside consultation
 
You might not be covered on HIPAA, but it seems that some information came out, that you were not prepared to come out in so far as the other doctor revealed something you had said.

If you had been covered on HIPAA then the other doctor was clearly able to identify the patient, whether or not that was your intention. IE a breach happened.

As far as discussing stuff in the lounge, it is a larger open area with many people talking. Someone can accidentally hear something about someone they know, and a breach has happened.

It is disrespectful and dehumanizing to use the lounge format to discuss patients. It makes me sick to my stomach to think it is regularly happening. Hopefully you are inaccurate about that.

It also seems you are exclusively focused on what the other doctor might have done wrong, without taking any responsibility for the fact that you opened your mouth and went blabbering to begin with.

Da Friendly Puter Tech

William Reid October 10th, 2009 09:13 AM

Re: Abuse of curbside consultation
 
The "doctor's lounge" in most hospitals is not some large living room, but isually a few chairs and a coffeepot near the dictation area. It is indeed reasonable -- and often a good idea -- to discuss clinical matters there, where useful information can be exchanged in relative privacy and informality, whether in the interest of a mutual patient (for which patient permission is rarely required, though often good to get), as an informal clinical consultation, or for some educational purpose (such as discussing the merits of a treatment or procedure, and perhaps giving important examples). The point of my earlier comments was not to discourage any of those.

The issue is privacy, especially when patient identification isn't clinically relevant to the discussion, not location. Putting a gag on clinical and professional communication between doctors (and other health care professionals) would be a very bad thing to do.

moviedoc October 12th, 2009 12:40 PM

Re: Abuse of curbside consultation
 
Puter Tech need not worry. That's what "professional" is all about. As long as the communication really is "legitimate" the consequence is almost always better care for the patient, and among docs these communications are almost always very respectful.

D.Biami December 2nd, 2009 09:33 PM

Abuse of curbside consultation
 
Who is they?

We know nothing about you or your circumstances. If they have jurisdiction and will investigate, why not ask "Protection and Advocacy" to take a look?


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