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Short-Term Patient Care

Conflicts between attending physicians and house officers may be divided into disputes that involve short-term patient care decisions and disputes that are administrative in nature. The short-term disputes are the primary quality control problem because they usually involve a disagreement over appropriate patient care. These short-term disputes evolve from one of two situations; a lack of common information about the patient, or actual therapeutic disagreements. The first situation arises when only one physician is familiar with the patient's condition. In some cases, the house officer performs all the patient care, and the attending staff member advocates a therapy based on insufficient information. This situation usually arises in teaching hospitals where house officers admit the patients, perform the initial history and physical, and begin therapy before the patient is ever seen by an attending staff member. In other cases, it is the attending physician who is familiar with the patient's condition. This usually occurs in hospitals with limited teaching programs and few house staff members. The problem here arises when a house staff officer questions an attending physician's orders without knowing the full background of the patient's illness. Regardless of which physician has a better grasp of the patient's condition, there is likely to be dispute over the appropriate therapy.

Disputes arising from disagreements over the patient's condition must be distinguished from disputes that arise when the attending physician and the house staff member both agree on the patient's condition but disagree about what therapy must be undertaken. When the dispute arises because of a disagreement over the patient condition, the person or committee charged with resolving the dispute must investigate the patient's condition. This will require a review of the medical records and may also require questioning or examining the patient. When the dispute center around different therapies for the same problem, the investigation need involve only the medical question of the standard of care for the patient's condition. This may be resolved by the use of testbook and expert consultations.

When a decision has been made, the legal problem lies in the enforcement of that decision. When the decision is to overrule the house officer, it is simple to implement. The hospital administration may simply ask the nurses to follow only the attending physician's orders. At the same time, however, a written report detailing and answering the house officer's objections should be put in the patient's chart. When the decision is to overrule the attending physician's orders, the patient should be informed of the dispute and allowed a voice in the decision. This is crucial when the attending physician was chosen by the patient and has an ongoing relationship with the patient. It is much less important if the only physician the patient has ever seen is the house officer. In either case, the patient should not be treated as a pawn or be kept in the dark about the dispute.

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