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A recent decision by the North Carolina Supreme Court allows the patient to sue the on-call attending physicians for the alleged negligent supervision of her labor and delivery. In the case of Rouse v. Pitt County Memorial Hospital, Vickie Rouse sued the hospital, the residents, and attendings involved in her labor and delivery for negligent medical care. She also sued the attendings, claiming they negligently supervised those residents.
Vickie Rouse was admitted to Pitt County Memorial Hospital in labor. She was treated by three residents over the next twelve hours. Drs. Mackenna and Borchert were the on-call attending obstetricians for most of this period. Dr. Mackenna was at the hospital during his on-call shift, but the residents did not ask him to review the situation. Dr. Borchert took over the call duties from his home at the end of Mackenna's shift.
When one of the residents called Dr. Borchert, he came in to the hospital and ordered an immediate cesarean section. The Rouse infant was born without spontaneous respirations, was resuscitated, intubated, and transferred to the neonatal intensive care unit. He later developed seizure problems and cerebral palsy and was found to be profoundly mentally retarded. Rouse sued the hospital and caregivers.
Drs. Mackenna and Dr. Borchert asked the court for summary judgment—a judge's decision to drop them from the case. Their position was: even if the court accepted everything the patient alleged, there was no real case against them. The trial court agreed with this logic, but later appeals courts did not agree, bringing the attendings back into the suit.
The North Carolina Supreme Court allowed this case to go forward against the attendings because they felt there was a question of whether the supervision provided to the residents was sufficient to meet the standard of care. The court explained that simply remaining at home available to take calls is sometimes—but not always—sufficient.
The parties dispute many of the facts in this case. Dr. Mackenna's usual practice was to make rounds of the labor and delivery ward, but there is no evidence that he did so on the day of Rouse's delivery. Dr. Borchert's practice was to call in and speak with the residents at the beginning of the on-call period to review all the cases. Again, the record is silent on whether or not he called.
The standard of care is disputed as well. Hospital policy required attendings to review all clinical entries made by trainees. An expert called by the attendings stated that the standard of care allowed an attending to take a call from home "unless a problem was present or specifically anticipated." His opinion raises the question of whether the attendings should have taken more steps to determine if a problem was present.
Many of the problems in this case might have been prevented if the residents had contacted the attendings for advice at an earlier stage. However, calling in an attending is not always an easy decision for a resident Some programs, or even individuals, may overemphasize independent functioning and therefore discourage residents from seeking advice or assistance. A resident who is trying to decide whether to call in an attending should consider the potential harm to the patient and err on the side of caution.
But the import of the North Carolina decision is that the attendings have a duty to supervise. Relying on trainees to notify attendings about problems is not sufficient in every situation. For example, a supervisor should not rely on a intern with limited diagnostic skills to call when encountering specific diagnoses.
Supervising physicians should assess the competence of trainees in several areas. Supervisors should look at trainees’ level of skill in diagnosing, trainees’ level of skill in treating, and trainees’ ability to discern when to act independently and when to seek help. A highly-skilled but overconfident fellow may need more feedback from a supervisor than a less-skilled resident with a solid understanding of when to call in a supervisor or specialist.
The performance of the fellows, residents, and interns in each rotation needs to be critically evaluated.
Proceeding through various rotations should not be automatic. If, for example, a resident fails to properly interact with the attendings on a service, then corrective action should be implemented, including education. Today, the practice of medicine requires the interaction of many specialties. Therefore, providing good care for our patients requires a knowledge of when and how to interact with other physicians.
Finally, teaching residents when they need to seek advice and consultation is an important aspect of the attending’s duties. There could be specific lectures on this topic with sample cases for the residents to consider. If the attending or the institution is involved in a lawsuit involving allegations of failure to supervise, evidence of such educational activities may be very helpful.
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