COVID-19: It changed the world but did it change your practice?

The world has not been the same since the pandemic, and clinicians also had to adapt their practice in order to reduce the risk of COVID-19 transmission. Otherwise, clinicians would run the risk of getting a complaint or claim, as illustrated in the following case studies by Dr Sara Sreih, medicolegal consultant and Peter J Mordecai, claims manager at Medical Protection.

 

Case study A

The patient contacted Dr A about colorectal bleeding. Due to the 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 diagnosed the patient with an anal fissure and prescribed a suppository. 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, and haemorrhoids were identified. 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 their wish to undergo otoplasty to reduce their ear protrusion. The patient’s consent was obtained, and the operation was successful.

Following the procedure, Dr Z provided the patient with their standard advice regarding care of the surgical site. However, this had not been updated in light of the pandemic. In particular, the doctor 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 re-developed, and the patient required further surgery and brought a claim against the doctor.

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 member decided not to see the patient because of local regulated restrictions, which only allowed urgent appointments to be face-to-face. However, the member 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 member to treat the patient in line with the provisional diagnosis, a follow-up 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 his standard post-operative instructions and failed to consider the impact that the COVID-19 pandemic had 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, they proceeded to make a definitive diagnosis of a condition that required a physical examination to confirm. In such circumstances, you should consider whether a further face-to-face consultation would be required. The patient should also be advised of the limitations of the consultation and the rationale behind advising an in-person consultation, as well as the risks of not attending, so that they 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 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 the case study B, the doctor should have updated their post-operative 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.

Although restrictions have eased since 2020, the healthcare system has not reverted to pre-pandemic normalities. It is, therefore, important to review your systems and processes to meet the ongoing developments of the pandemic. Here are some practical things to consider following the case studies above:

1. What additional risks/limitations do COVID-19 prevention rules create for my 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. If you believe that a face-to-face consultation is required, then the patient must be informed of the reason for this, and risks in not doing so. The Malaysian Medical Council (MMC) published an advisory on virtual consultation (during the COVID-19 pandemic) reminding physicians that the use of technology does not alter the ethical, professional, and legal requirements in the provision of care. This means the same standards of care apply to telemedicine as they do with face-to-face consultations. [Available at: https://mmc.gov.my/wp-content/uploads/2020/04/MMC_virtualconsultationADVISORY.pdf. Accessed on 22 March 2022.]

3. If I hold a virtual consultation, am I 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 then make sure there is appropriate follow up arranged, or at least sufficient safety netting in place, should the condition not improve or deteriorate further.