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If the hospital thought it had something there, it could have tried raising this, but as far as I can see it didn't.

My guess is that this line gets shot down because the lawyers for Warren are going to ask Dinter to explain about how this mechanism where the NP admits patients over his objection works, maybe giving examples, and the hospital knows there aren't any examples because in fact policy is to never allow this to happen. It's going to cause the court to dwell on what you did wrong (not admitting the patient), which isn't what you want to happen if you're worried the court may rule against you.

It's pretty obvious that they're hiding behind the idea it's a kerbside consult when really it's a gatekeeper role, and courts are ideally placed in law to judge that sort of thing because they're obliged to work with events that really happened whereas lawmakers can live in a hypothetical universe. Maybe hypothetically there is no "gatekeeper" role, but if the fact is that every admission goes through one of these hospitalists, then de facto that's a gatekeeper.

The patient could have been admitted over the objection of the hospitalist by going to the emergency room and being admitted after evaluation there. This is how most patients are admitted.

> Baldwin testified that a hospitalist disagreeing with a request for admission “doesn’t happen very often,” but when it does, a medical professional will select another path to hospitalization. The one time it happened to her, Baldwin “had the patient go to the emergency room at Fairview Range.”

So at least she has a 100% success rate in bypassing the gatekeeper.

> Dinter also implied that it would be pointless to admit the patient. But does that mean he _refused_ to admit her?

He said it in the context of someone explicitly asking him to admit a patient, of course it's a refusal! The most commons way to refuse to answer questions likewise doesn't explicitly involve shouting "I refuse" loudly.

Let's agree that a reasonable person would see that as a refusal.

In fact, let's make the refusal even more explicit.

Let's suppose that he flat-out said, "I don't think she needs emergency care, and if you send this patient to the ER, I will refuse to treat her."

Even so ... isn't it ultimately on the NP -- who seemed to grasp that he was blowing her off -- to either get a second opinion or (ideally) use her own medical training to determine that the patient really should go to the ER, no matter what he says, knowing that he can't actually refuse to treat her?

Stating that you intend not to do something, after all, is not always the same as actually refusing to do it.

That's not the most compelling argument, I know.

But I do worry about the broader implications of this ruling. Should physicians fear malpractice claims arising out of consultations with colleagues? In what cases can you feel free to give your opinion "off the record," with the understanding that the person who has consulted you will bear ultimate responsibility for the treatment they are providing?

I think you're setting this up as a "just following orders" argument on the part of the NP, which justifiably should be shot down. But this isn't just her following orders, it's her asking for an opinion on something outside of her knowledge. Just because she had a gut feeling that he was wrong doesn't make her culpable. _Nurses should accept the opinions of doctors in regard to diagnoses because the doctors have specifically trained for this to a much greater extent than nurse practitioners._

It seems to me that if NPs are incapable of making (at least some) correct diagnoses and must defer to the expertise of a supervising doctor, then they cannot also be responsible for the doctor being incorrect.

Either they are trained well enough to make the decision on their own (which would mean the NP shouldn't need permission for this patient to be admitted) or the doctor is actually the person who is responsible for the patient's well-being.

> isn't it ultimately on the NP

No, because we don’t live in a world where only one person has to be responsible for every outcome.

Multiple people can share responsibility (and legal liability) for an outcome. In this case, the NP may bear some responsibility for the reasons you outlined. In fact the NP and her organization were sued and settled out of court already:

> At some point prior to that date, Justin Warren “sued Essentia Health for the alleged malpractice of its employees, Simon and Baldwin.” (p. 6) That case was settled out of court.

So, the NP may bear some responsibility, but there’s no reason why that should be the end of the investigation as to who else may bear some responsibility.

> Still concerned about Ms. Warren’s condition, Simon then spoke to Dr. Jan Baldwin, her “collaborating physician” at the Essentia clinic. Amazingly, Baldwin, who also did not examine Warren, agreed with Dinter – Warren was suffering from out-of-control diabetes. (Neither court opinion indicates whether Warren had been previously diagnosed with diabetes.) At that point, Simon relented.

Based on my reading of that block from the article, she did get a second opinion. Once you've got two more credentialed professionals agreeing on something, it's a lot harder to justify going against their opinion.

I think the "curbside consult" defense is dubious, since, as far as I understood from the article, Fairview is the go-to hospital for residents of the plaintiff's area.

I agree with you on the second part. I wonder if there is actually a clear chain of responsibility in patient->clinic->hospital relationship.

"I, a doctor in a position of authority don't think that it would be valuable to admit this patient. But please Nurse who I have a semi-managerial relationship with, feel free to admit this patient if you think it would be valuable."