COVID-19 has changed healthcare but has it changed your practice?

Dr. Sara Sreih
Medicolegal Consultant
Medical Protection (MPS)
Peter J Mordecai
Claims Manager
Medical Protection Society (MPS)
14 May 2022
COVID-19 has changed healthcare but has it changed your practice?

The world has not been the same since the pandemic. At the time of writing, Hong Kong is contending with a further wave of coronavirus disease 2019 (COVID-19) and clinicians have to continue to adapt their practice in order to reduce the risk of transmission. While each wave of the pandemic can change rapidly, clinicians must remain vigilant to minimize the risk of getting a complaint or claim. This risk is illustrated in the following case studies by Dr Sara Sreih, Medicolegal Consultant, and Peter J Mordecai, Claims Manager, at Medical Protection, along with a timely update on guidance from the Medical Council of Hong Kong (MCHK) on the practice of telemedicine.

CASE STUDY A
The patient contacted Dr A about colorectal bleeding. Due to COVID-19 restrictions at that time, Dr A conducted a virtual consultation. Upon hearing the patient’s history and with no 'red flag' symptoms, Dr A made a diagnosis of an anal fissure and prescribed a suppository to the patient. Dr A did not arrange a follow-up appointment.

The patient's symptoms continued for several months and he sought a second opinion. A sigmoidoscopy was performed, which identified haemorrhoids. This was subsequently treated.

The patient brought a claim against Dr A. One of the allegations was a failure to perform a physical examination at the first consultation, resulting in a delay in diagnosis.

CASE STUDY B
This patient consulted Dr Z with a wish to undergo otoplasty to reduce ear protrusion. The patient’s consent was obtained and the operation was successful.

Following the procedure, Dr Z provided the patient with standard advice regarding care of the surgical site. However, this advice had not been updated in light of the pandemic. In particular, Dr Z did not advise the patient about the risk that wearing facemasks (with ear loops) may adversely affect the outcome of the procedure.

Unfortunately, the protrusion redeveloped. The patient required further surgery and brought a claim against Dr Z.

Outcome
Unfortunately, Medical Protection was unable to defend the claims brought by these patients simply because the doctors had failed to update their practice in accordance with the context of the pandemic.

In case study A, the doctor decided not to see the patient because of local regulated restrictions, which only allowed face-to-face appointments for urgent cases. However, the doctor then proceeded to make a diagnosis of an anal fissure. Whilst it was acceptable for the doctor to make a provisional diagnosis, in this case a definitive diagnosis was made instead in the absence of a physical examination.

In addition, whilst it was appropriate for the doctor to treat the patient in line with the provisional diagnosis, a follow-up appointment should have been arranged. This would have allowed the doctor to monitor the patient and the outcome of the treatment to see whether further investigation was required or whether the diagnosis should be revised.

In case study B, the doctor recited the standard postoperative instructions and failed to consider the impact of the COVID-19 pandemic on these. In this case, the common practice of wearing a facemask had the potential to adversely affect the patient's outcome, and the patient should have been advised of this risk.

Learning points
In case study A, whilst the doctor was correct in holding an initial telephone conversation, he/she proceeded to make a definitive diagnosis of a condition that required confirmation by a physical examination. In such circumstances, doctors should consider whether a further face-to-face consultation would be required. The patient should also be advised of the limitations of the virtual consultation and the rationale behind advising an in-person consultation, as well as the risks of not attending, so that the patient can make an informed decision. Even discussions about appointment options should be recorded in the patient notes.

Taking into account the limitations of virtual consultations, it is even more necessary to consider appropriate safety netting advice. Although there were no 'red flag' symptoms indicating conditions such as cancer at Dr A's virtual consultation, it is possible that these could have developed later, and a more serious diagnosis could have been missed without appropriate safety netting in place.

Likewise, in case study B, the doctor should have updated his/her postoperative advice to take into account how normative behaviour resulting from the pandemic may adversely affect the outcome of the procedure, and made the patient aware of the adaptations required.

Practical considerations
The healthcare system has not reverted to prepandemic normalities. It is therefore important to review your systems and processes to meet the ongoing developments of the pandemic. Here are some practical considerations following the case studies above:

1.      What additional risks/limitations do COVID-19 prevention rules create for the patient? The patient should be informed of these and of ways to mitigate the risks.

2.      Does the patient require a face-to-face consultation or is a virtual consultation sufficient, and safe, to not compromise the patient’s care? Even if it is the patient’s preference to have a virtual consultation, do consider the patient’s presentation and risks. [https://specialty.mims.com/topic/keeping-yourself-safe-when-consulting-remotely?channel=multi-specialty] If you believe that a face-to face consultation is required, the patient must be informed of the reason for this, and risks in not doing so. The MCHK published guidance in 2019 on the practice of telemedicine, advising that the standards of care that protect patients when consulting in person apply equally when conducting telemedicine. It is advised that a "credible doctor-patient relationship" must be established prior to consulting remotely with a patient. [https://www.mchk.org.hk/files/PDF_File_Ethical_Guidelines_on_Telemedicine.pdf]

3.      If a virtual consultation is held, are you able to make a definitive diagnosis? Some diagnoses can be reached, with management plans safely initiated without seeing a patient face-to-face. Other diagnoses may be contingent, however, on an in-person physical examination.

If you make a provisional diagnosis, make sure there is appropriate follow-up arranged, or at least sufficient safety netting in place, should the condition not improve or deteriorate further.

In addition to the two case studies, clinicians will be interested in MCHK's updated guidance on the practice of telemedicine. In early March 2022, MCHK published 'Questions and Answers to the Ethical Guidelines on Practice of Telemedicine', which should be read in conjunction with the 2019 guidance. [https://www.mchk.org.hk/files/Questions_and_Answers_to_the_Ethical_Guidelines_on_Practice_of_Telemedicine.pdf]

The full guidance can be accessed online. However, some particular points of interest are noted below:

•       MCHK advises that it is not mandatory, but it is advisable for a face-to-face consultation to have taken place before seeing a patient remotely. The guidance reinforces the need for a credible doctor-patient relationship to be established, and advises that there is no prescriptive path to this, as this depends on the circumstances of each case. However, the clinician must also consider whether it is necessary to conduct a physical examination and the need to have access to the patient's medical records.
•      There is still a need for accurate, clear and contemporaneous records when consulting remotely, to assist the clinician and other healthcare professionals in continuing the patient’s care, and to protect the legal interests of both the doctor and the patient.
•      Any recording, whether audio or video, of a remote consultation must only be taken with the patient's prior consent, which should then be documented in the patient's record.
•      Further to the advice on prescribing remotely — found within the 2019 guidance — MCHK also advises clinicians to be aware of the provisions of the Hong Kong Medical Association's Good Dispensing Practice Manual and the MCHKS Guidelines on Proper Prescription and Dispensing of Dangerous Drugs. [https://wmv.thkma.org/pdf/Good_Dispensing_Practice_Manual_2nd_Edition_Amended_Version.pdf; https://www.mchk.org.hk/english/code/files/Revised_Appendix_E_2018.pdf] Caution is advised regarding dispensing dangerous drugs through a third party.

Earlier in the pandemic, MPS wrote in more detail about the factors to consider when prescribing remotely. Such factors include:

•      Whether a clinician has enough information about a patient’s health;

•      Whether any limitations, such as the need for a physical examination, are considered;

•      Ensuring that adequate discussion takes place about medication, that relevant instructions are communicated to the patient, and that steps are taken to ensure the patient has understood this information;

•      Ensuring if a patient is unable to collect medication in person, that adequate authorization has been provided for a third party to do so on the patient’s behalf. As above, caution is advised regarding dispensing dangerous drugs through a third party.

If clinicians are in doubt about the risks they face when consulting or prescribing remotely, they should contact their medical defence organization for advice.

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