I want to comment on Dr. George Hossfeld's column. (EMNow 2011 Oct 20; http://bit.ly/InappropriateExperts.) Medical malpractice is legal fault by a physician. (Black's Law Dictionary. 8th ed. Eagan, MN: Thomas West Publishing; 2004.) It arises from the failure of a physician to provide the quality of care required by law. When a physician undertakes to treat a patient, he takes on an obligation enforceable by law to use minimally sound medical judgment and provide minimally competent care in the course of the services he provides: standard of care, which originates from multiple sources including the scientific literature, policy statements from professional organizations, and state and federal law. Expert witness testimony is usually necessary to provide evidence of the standard of care. (Wis L Rev 1991;1991:1113.)
Throughout judicial history, courts deliberating medical malpractice cases have encountered assertions that the standard of care may vary from one locale to another. This locality rule was based on the premise that rural physicians might not have the same experiences or opportunities for education as their colleagues in larger cities, and it would be unfair to hold them to the same standard of care. (JAMA 2007;297:2633.) As a result, only physicians who practice in that community could serve as expert witnesses.
Most states have moved away from recognizing more than one standard of care, and have abandoned the locality rule. These states recognize that medical education has become standardized under national accreditation and continuing medical education programs. With the availability of modern technology, rural and urban physicians generally have the same access to information for patient care. (JAMA 2007;297:2633.) On the same matter, Mississippi Supreme Court Justice James Robertson reasoned:
“We would have to put our heads in the sand to ignore the ‘nationalization’ of medical education and training. Medical school admission standards are similar across the country. Curricula are substantially the same. Internship and residency programs for those entering medical specialties have substantially common components. Nationally uniform standards are enforced in the case of certification of specialists. Differences and changes in these areas occur temporally, not geographically.” (Hall v. Hilbun, Supreme Court of Mississippi, 1985. 466 So.2d 856.)
Similarly, medical specialty organizations charged with administering specialty board certification examinations do not administer separate exams for community physicians and academicians. Similarly, at Yale, we do not segregate our emergency medicine residents into two groups based on where each resident envisions he might practice medicine, and then proceed to teach each group a different standard of care.
With the judicial pendulum swinging so far in favor of a national standard of care, it would be difficult to imagine a rational argument that physicians of one specialty should be held to different standards of care based on whether they practice medicine at a community hospital or an academic teaching institution.
I would be remiss if I failed to recognize that differences exist in the resources each hospital can access. It falls well within my understanding that a community hospital may not have an in-house neurosurgeon or invasive cardiologist to care for patients in need of their expertise. I understand this despite the fact my practice lies within the four walls of a large teaching institution. I am thankful for the access I have to these services in the hospital where I work and teach. What I also understand is despite the differences between each institution, the standard of care a patient deserves is the same whether he is taken to our institution or the community hospital.
While each hospital operates under the same standard of care, how they effect that standard may vary. In my practice at our institution, the stroke and trauma team are a phone call away. For the neighboring community hospital, we are a phone call away. Telemedicine and prearranged collaborative protocols help bring expertise to areas without the on-call expertise a patient in a community facility might need. In the end, when the need of a patient outweighs the level of care a facility can provide, that patient should be transferred to a facility capable of providing the requisite level of specialty care. All this is accomplished within one overarching standard of care.
Edward Monico, MD, JD
New Haven, CT
EMN Quick Poll
How many of your patients leave without being seen? Read our cover story, “Most Vulnerable Patients at Risk for Not Being Seen,” and vote on EM-News.com.