Medical directors play an integral role in the care of patients in the prehospital setting. Along with the ability to have a positive impact on the care of the patient goes the responsibility to strive for the best possible outcome. Medical directors must ensure that they carry out their roles with the due care which the law will impose on them. The failure to carefully carry out their roles may not only result in harm to the patient, but also to liability of the physician and the physician’s employer.
Define the circumstances which must be present in order to form a physician-patient relationship.
List the components of the physician-patient relationship.
Identify whether a physician-patient relationship has been formed given a set of facts.
Discuss the nature of the physician-patient relationship when a physician responds to the field to assist with treatment.
Identify potential liability issues when a physician provides online and off-line medical direction.
Explain the roles of the physician in providing off-line medical direction
Describe ways in which EMS agencies can obtain useful feedback and detail a method for handling complaints.
DEFINE THE STANDARD MEANING OF PHYSICIAN-PATIENT RELATIONSHIP
In the United States, the physician-patient relationship is defined on a state-by-state basis through either judge made case law or state statute. As a result, the definition of this relationship varies from state to state. Physicians are generally not obligated to treat a patient unless they choose to do so or have assumed a duty to do so, although there are certainly exceptions to this rule. A patient-physician relationship is formed when a physician affirmatively acts on behalf of a patient by examining, diagnosing, or treating the patient or by agreeing to do so. Once the physician consensually enters into a relationship with a patient in any of these ways, a legal contract is frequently formed in which the physician owes a duty to that patient to continue to treat the patient until the relationship is actually and properly terminated.
The American Medical Association has commented on the physician-patient relationship as follows:
The practice of medicine, and its embodiment in the clinical encounter between a patient and a physician, is fundamentally a moral activity that arises from the imperative to care for patients and to alleviate suffering.
A patient-physician relationship exists when a physician serves a patient’s medical needs, generally by mutual consent between physician and patient (or surrogate). In some instances the agreement is implied, such as in emergency care or when physicians provide services at the request of the treating physician. In rare instances, treatment without consent may be provided under court order…. Nevertheless, the physician’s obligations to the patient remain intact.
The relationship between patient and physician is based on trust and gives rise to physicians’ ethical obligations to place patients’ welfare above their own self-interest and above obligations to other groups, and to advocate for their patients’ welfare.
Within the patient-physician relationship, a physician is ethically required to use sound medical judgment, holding the best interests of the patient as paramount….
Attorneys may look at this relationship a bit differently. The physician-patient relationship is most often formed voluntarily with the mutual consent of the physician and the patient. The relationship involves an explicit or implied set of expectations between an individual and a physician which has reasonably imposed a duty of care on the physician to diagnose and/or treat the patient within the standard of care of the practice of medicine. The relationship relies on the actual or implied trust of the patient in the knowledge and/or skills of the physician. The formation of the relationship dictates that a physician has or should have the expectation that the patient is relying on the physician for present and/or future diagnosis, treatment, and/or evaluation.
The physician-patient relationship, once formed, imposes a duty on a physician to diagnose and treat a patient within the standard of care. The resulting relationship is one where a patient either explicitly or implicitly desires the physician to provide medical diagnosis and/or treatment. The goal of the relationship usually is for the physician to provide diagnoses of a condition, an answer to a question and a solution to a medical and/or health concern and issue. The relationship is based on the patient’s trust in the physician to provide timely and accurate answers and/or solutions. Although not all medical conditions are capable of being treated to the point of remission or healing, the physician-patient relationship is one of an expectation by the patient that the physician is knowledgeable in the subject matter or will if necessary refer the patient to a physician capable of performing such a diagnosis and/or treatment.
However, a relationship is not formed simply because a patient has an expectation that the physician has become obligated to diagnose and/or treat the physician. The patient’s expectations must be based on a reasonable set of circumstances which bind the physician to become bound to a duty of care to the patient. In determining whether a physician-patient relationship has been formed, courts frequently wrestle with the underlying facts of the alleged relationship between the physician and the individual.
Although in most instances determining whether such a relationship has been formed is not difficult, persons who have come in contact with a physician in some manner frequently allege that they have earned a duty for care from a physician to be treated as a patient. Not all physicians will agree that the level of contact they have had with an individual resulted in a duty of care owed to that individual as a patient.
Certain state statutes and judge made law impose only limited physician-patient relationships in various instances, such as when a physician is required to evaluate a patient’s medical condition in order for the court to make certain findings on the patient’s physical or mental well-being or when an individual is required to have a physical and/or mental examination prior to employment. These situations are discussed more in detail below.
Numerous courts have engaged in fact-finding missions of whether a physician’s contact with an individual rose to the level of a physician-patient relationship.
Questions which could arise in the emergency medical services industry are ever abundant. Some potentially common situations are as follows:
A physician provides medical control over the phone or radio, instructing or confirming the administration of a treatment or medication to a patient in an ambulance.
A physician responds directly to a scene of an accident to assist with the treatment of a patient, such as by removing a limb in order to extricate the patient from a vehicle.
A member of a fire department or ambulance services asks what seems like an innocuous medical question of their medical director as to the member’s own medical or health issues.
A paramedic is permitted to operate “under the license” or “under the supervision” of a physician, and the physician oversees the competency of the paramedic.
A physician reviews the care of emergency medical service providers under quality control, and permits the providers to operate in the field, having deemed them “competent” providers with adequate knowledge and skills.
A physician in his or her off time happens upon the scene of an accident or medical emergency, and (a) provides advice to the emergency medical service provider, (b) actually provides instructions to the emergency medical service provider, or (c) actually treats the patient.
Although the creation of a physician-patient relationship is generally easy to determine, as the patient usually seeks out the physician, and the physician then accepts the patient as a client, the relationship is not always clearly established. More difficult questions of whether such a relationship has been formed are, for example:
A physician with no relationship to the emergency medical service happens upon a scene of a medical emergency and asks a paramedic if he or she needs assistance with treating a patient, and the paramedic refuses assistance or alternatively accepts assistance.
A physician offers advice to a treating paramedic, which the paramedic utilizes in its treatment.
A physician with no relationship to the emergency medical service happens upon a scene of an accident, but offers no medical advice to the patient or the paramedic, but simply assists the paramedic in carrying out a manual task such as intubation or application of a splint.
A physician directly treats the patient, but the patient is unconscious and unaware of the treatment.
As stated above, the relationship is often a voluntary relationship where the physician can choose to accept the individual as a patient or choose not to do so. Most frequently, physicians can refuse to accept an individual as a patient for almost any nondiscriminatory reason (such as gender, race, sexual preference).
In some instances, physicians have waived the right to accept patients, such as physicians who work in emergency rooms and are presented with patients in potentially emergency situations, or physicians who are under a contract with a private or government insurance program to accept patients.
Additionally, some states impose duties of care on all individuals to take reasonable action, for example, Minnesota, Vermont, Hawaii, Rhode Island, and Wisconsin. What defines an action to be reasonable or unreasonable is a matter of case law. In these few states, however, the failure of a physician or emergency medical technician to render care within the scope of their authorized practice may be deemed a violation of the state statutes.
Physicians may choose to refuse to take on individuals as patients for a variety of reasons, including but not limited to:
The treatment request is beyond the physician’s competence.
The treatment request is scientifically or medically invalid or unnecessary.
The treatment request is incompatible with the physician’s personal beliefs.
PHYSICIAN-PATIENT RELATIONSHIP IN CLINICAL AND HOSPITAL PRACTICES
As stated, states vary in how they define a patient-physician relationship. However, a patient-physician relationship is generally formed when a physician affirmatively acts in a patient’s case by examining, diagnosing, treating, or agreeing to do so. Once the physician enters into a relationship with a patient by providing an examination, diagnosis, and/or treatment, or simply agrees to do any of these actions, a legal contract is likely formed in which the physician owes a duty to that patient to continue to treat or properly terminate the relationship.
Broken into its parts, the relationship frequently requires the following components:
A request, either expressly or implicitly, by the individual to the physician to provide a diagnosis and/or treatment
An acceptance by the physician or a preexisting legal obligation of the physician diagnose and/or treat the physician
Not all states require that there be an actual agreement between the physician and the patient in every instance. In Oregon a court held that “in the absence of an express agreement by the physician to treat a patient, a physician’s assent to a physician-patient relationship can be inferred when the physician takes an affirmative action with regard to the care of the patient.” A patient-physician relationship was formed because the physician took an affirmative action in rendering an opinion on the course of the patient’s care.1
States commonly recognize that a physician who actually treats a patient has a duty of care toward that patient.2 In limited situations, courts have held that diagnosing patients does not necessarily create a physician-patient relationship.
Even though physicians may not form a physician-patient relationship with certain individuals, the physician may still owe the individual a limited duty of care.
For example, physicians also engage persons in other situations, such as to perform preemployment screening or “fit for duty” evaluations. Courts have generally held that no physician-patient relationship exists when a physician merely examines a patient on behalf of the patient’s employer. However, if the physician treats the patient for any condition, such a relationship has been formed (see article for cases).