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I think that everyone would agree that today's workplace environment has become much more informal when compared to a mere ten years ago. From the dress code; to the relationship between employer and employee; to the manner in which staff and clients interact; things have moved to a point of seeming relaxed if not down right free spirited. For the most part this has been a positive evolution. However, in many service oriented businesses, especially those wherein the employer is a licensed professional, the fact that many clients' questions or concerns are handled (or at least attempted) by staff rather than the professional can be significantly problematic, even dangerous. This is clearly the case in the medical practice arena. Too often unqualified personnel attempt to field the patient's questions and to give medical advice or instruction. I am not suggesting that the nurse or office employee doesn't mean well but I am advocating that it stop for more that one reason. First, and perhaps most obvious, it is against Texas law for anyone to practice medicine without a medical license. Interpreting physical complaints and symptoms and giving advice and instruction in the face of the same clearly crosses into the province of the physician or other licensed advanced practitioner. Second, and in my view more important, such conduct can clearly endanger the well being of patients no matter how innocent or well intentioned the nurse or office employee may be in offering the advice. Either way you, the licensed practitioner, expose yourself to liability for the faulty and or erroneous advice provided by your nurse or office employee even though it may have been given without your knowledge and acquiescence. Consider the following case and then ask yourself if the burden of personally fielding or returning the calls of your patients isn't less than the problems created by allowing inexperienced, unqualified, or unlicensed employees to do so.

The patient was a 36 year old mother of two boys who had suffered with hemorrhoids for several years. She finally decided to have a surgical procedure in the hopes of obtaining some relief. As a matter of routine, the surgical specimen was sent to pathology for evaluation. The report came back demonstrating evidence of anal cancer. Despite the diagnosis the prognosis was encouraging given the stage and extent of involvement. A referral to oncology was made and, after consultation among specialist, a course of chemo and radiation therapy was instituted. At that point the patient carried a cure rate of 80% or more according to the experts.

After approximately two weeks of chemo and a single course of radiation the patient began to experience significant vomiting, diarrhea, and mucositis. As you would expect this lead to dehydration and affected the patient's nutritional intake/retention. She also experienced a seventeen pound weight loss. Toward the height of her therapy induced illness the patient's husband became exceedingly concerned with his wife's lethargy and despite a scheduled appointment in a couple of days he telephoned the oncologist's office to report the symptoms and obtain advice as to her condition.

The nurse at the oncologist's office had been employed with the physician for many years and had often relayed messages to and from the physician for patients suffering from therapy related sequalae. With that experience and with all good intentions, she informed the husband that it was normal for his wife to be nauseous and to vomit in light of the chemo radiation treatments. She also told him that the mouth sores were common and that the weight loss went hand in glove with the inability to hold fluids and food down. She told the husband to give the patient some Gatorade and to be sure and tell the doctor about his concerns at the appointment on Monday morning. The patient's call was not relayed to the oncologist.

Over the next 24 hours the patient's condition failed to improve so her husband elected to take her to the ER on Saturday evening. On admission she was severely neutropenic with an ANC of less than 100. She also presented hypothermic with a tympanic temperature of 94, tachycardic with a sustained pulse of 154, tachypneic with respirations of 36, thrombocytopenic with platelets of less than 5000, and altered mental status.

Despite admission to the ICU for rehydration, neupogen, platelets, and antibiotics, the patient died some 36 hours later. Suit followed with allegations of negligence against the oncologist including a failure to instruct his staff and or to have policies and procedures in place at the office to ensure that a patient's complaints and symptoms are relayed directly to the doctor.

The above case illustrates a common problem in today's medical practice - physicians that are quite busy with tenured employees feeling comfortable fielding patients' calls. Whether your nurse's or office employees' tendency to field questions and to provide medical advice is a matter of ego or a matter of merely trying to be helpful to the patient, the unqualified interpretation of and response to a patients' physical complaints and symptoms can have devastating effects for all concerned. If you have not done so already, or if you have come to the conclusion that most calls are an insignificant nuisance that can be handled by your nurse, much less the front office, I urge you to institute a strict policy to be sure that all patient calls are brought to your attention in a timely manner and to instruct your staff to refrain from interpreting complaints and offering medical advice/instruction to your patients without your knowledge.

Until next time remember: What you don't know CAN hurt you - and your patients!