Malpractice Risks for Hospitalists

Mark Crane


March 21, 2013

In This Article

What's Different About Hospitalists?

Hospitalists' patients tend to be sicker than those of primary care physicians, given that they are already hospital inpatients. Hospitalists also lack the long-standing relationship with patients that primary physicians have, so they have less knowledge of the patient's personality and background, and less experience with how the patient communicates.

"Plaintiffs' attorneys are beginning to see lawsuit material in the fact that hospitalists don't meet patients until their hospital admission or see them after discharge," says Stella Fitzgibbons, MD, a Houston-based hospitalist who reviews cases for both plaintiff and defense attorneys.

"Hospitalists are no more likely to be lawsuit targets than anyone else, though our short acquaintance with patients means we have to work harder at demonstrating our concern and competence," Fitzgibbons says. "We also admit more uninsured patients than many of our colleagues, and cutting corners because the hospital says to move them through faster is no way to practice medicine."

More than one third of hospitalists report shouldering an unsafe patient load more than once a week, leading to poor communication, treatment errors, potentially unnecessary tests, sloppy handoffs, and sometimes complications and death, according to a recent study published online in JAMA Internal Medicine.[1]

The online survey of 890 self-identified hospitalists found that 40% said their typical inpatient census exceeded safe levels at least once a month, and 36% said it happened more than once a week.

The unsafe workloads often have patient safety consequences and therefore the potential for liability suits, the authors said. Some 25% of the hospitalists said that they failed to fully discuss treatment options with patients; 22% offered potentially unnecessary tests, procedures, and consultations; 19% said that patient satisfaction declined; and 7% committed a treatment or medication error.

What Hospitalists Get Sued For

A study of closed claims by The Doctors Company found that the most common allegations involving hospitalists are improper management of treatment course, delay in treatment, failure to treat, diagnosis-related error (failure to diagnose, delay in diagnosis, or wrong diagnosis), improper medication management, and failure to monitor the physiologic status of the patient.

Poor Coordination of Care

Claims against hospitalists frequently identify poor coordination of care to be the cause of injury. Hospitalists typically comanage the patient's care with several physicians, and sometimes it's unclear who has the final responsibility for decisions.

For example, in one case in a large Midwestern hospital in 2010, CT and MRI revealed a large intracerebral hematoma and an arteriovenous malformation (AVM) in a 45-year-old patient admitted to the neurosurgery service. The patient's complaints of headache, nausea, and blurry vision weren't adequately addressed, owing to confusion about which service was supposed to monitor neurologic checks, says Diamond. The hematoma and AVM were removed during emergency surgery, but the patient never regained consciousness and died 4 days later.

Neither the neurosurgeon nor the hospitalist diagnosed the unstable hematoma that caused the brainstem herniation.

"The biggest error was that neither doctor was clear about who was in charge of the patient," says Robin Diamond. "The neurosurgeon believed the hospitalist was handling the patient's presurgery care, so he wasn't monitoring the neurologic checks. The hospitalist thought the surgeon was tracking those checks, so she didn't address them."

"Some patients who are admitted from the emergency department or through physician office practices don't even know what a hospitalist is," says Diamond. "At the time of introduction to a new patient, the hospital should have a clearly defined process that demonstrates the role of the hospitalist, how the hospitalist will relate to the surgeon, whom the nurses will contact should the patient ask to see the physician, how often the patient will see the hospitalist, and whether the patient will see the same hospitalist over a period of days or the hospitalist is rotating off-shift."

Stella Fitzgibbons, the hospitalist, agrees. "The primary care doctor should prepare the patient, letting her know that he'll check on her progress, but a hospitalist will be rendering the care," she says. "That's better than being assigned to a complete stranger."

Comanagement arrangements should be spelled out in a written protocol that clearly defines the roles of the attending physician and the consultant, recommends The Doctors Company. Hospitals need to specify at which points specialists will take over the patient's care and how handoffs between the 2 services must be performed.