New court ruling could mean trouble for physicians

By Naveed Saleh, MD, MS, for MDLinx
Published June 14, 2019

Key Takeaways

A lawsuit in one state now exposes physicians to greater malpractice liability—and has sent a chill up the spines of doctors throughout the nation. A court ruling in Minnesota found that the establishment of a physician-patient relationship is not required for medical malpractice. Will other states follow suit?

Historically, Minnesota law has required the existence of a physician-patient relationship for patients to sue. In the case of Warren v. Dinter, the Minnesota Supreme Court had to decide whether “a hospitalist’s alleged decision to deny a patient admission to a hospital may constitute professional negligence,” according to the Supreme Court’s ruling, which was issued on April 17, 2019.

The first lines of the final decision reads:

“A physician-patient relationship is not a necessary element of a claim for professional negligence. A physician owes a duty of care to a third party when the physician acts in a professional capacity and it is reasonably foreseeable that the third party will rely on the physician’s acts and be harmed by a breach of the standard of care.”

Let’s take a closer look at the ruling.

Conflict of conclusions

On August 8, 2014, a 54-year-old woman named Susan Warren presented to nurse practitioner Sherry Simon at the Essentia Health Clinic, Hibbing, MN. Warren reported three days of worsening symptoms of abdominal pain, fever, chills, cough, and shortness of breath. Simon ordered tests and deduced that Warren had an infection based on very high levels of white blood cells and needed to be hospitalized.

Because Essentia does not have a hospital in Hibbing, Simon, in standard practice, called Fairview Range Medical Center—a different healthcare system from Essentia—in an attempt to admit Warren. Simon was put in contact with Dr. Richard Dinter, one of the three Fairview hospitalists on call.

After listening to Simon present Warren’s case during an approximate 10-minute call, Dr. Dinter ultimately felt that Warren did not need to be admitted to the hospital, according to Simon. Of note, Dr. Dinter was unable to view Warren’s medical chart during his conversation with Simon.

In their testimony to the court, Simon and Dr. Dinter both disagreed on the diagnostic information shared during the call as well as their respective responses. Simon alleges that Dr. Dinter told her that the patient’s elevated white blood cell count was likely due to type 2 diabetes.

Still feeling that Warren should be hospitalized, Simon consulted with Dr. Jan Baldwin, who was Simon’s collaborating physician at Essentia. Dr. Baldwin also agreed that type 2 diabetes could be the underlying cause for Warren’s elevated white blood-cell count.

With this information in mind, Simon met with Warren and informed her that, after speaking with a hospitalist, she would not be admitted to the hospital. Simon then discussed a diabetes diagnosis with Warren, prescribed diabetes and pain medication, scheduled a follow-up appointment, and then sent her home.

Three days later, Warren was found dead from sepsis due to an untreated staphylococcus infection, which was confirmed upon autopsy.

Legal action and court rulings

On March 7, 2016, the patient’s son sued Dr. Dinter and Fairview Medical Center, alleging negligence resulting in Warren’s death. (Prior to initiating this legal action, Warren’s son filed a lawsuit against Essentia Health for the alleged malpractice of Simon and Dr. Baldwin; the case has since been settled.)

Per the ruling: “Dinter and Fairview moved for summary judgment, arguing that Dinter owed no duty of care to Warren because Simon had called Dinter only ‘for his thoughts as a hospitalist’ and, therefore, he had ‘provided his reactions … as a professional courtesy’ to Simon. They also argued that Dinter’s acts or omissions were not the proximate cause of Warren’s death.”

Importantly, the Minnesota Medical Association (MMA) teamed up with the American Medical Association (AMA) to file an amicus brief, which argued that expanding physician liability outside of the physician-patient relationship would damage the practices of physician collaboration and informal consultation—ultimately harming patients.

In the summary judgment, the district court sided with Dr. Dinter and Fairview Range Medical Center, and ruled that the informal conversation between medical colleagues did not establish a physician-patient relationship. Consequently, Warren’s son appealed, with the court of appeals also upholding the district court’s position in a divided, unpublished ruling.

One dissenting judge opined that Dr. Dinter and Fairview Range Medical Center were liable due to the “forseeable” nature of the consequences.

Ultimately, the Minnesota Supreme Court granted review of the suit, and issued this ruling:

“The court concludes that Dinter’s duty and a foreseeable risk of injury to Warren can be established by reason of his one-time, limited discussion with another medical professional: Simon. Factually, the court’s analysis is not complicated. Because Simon was unable to admit her patient to Fairview Range Medical Center without Dinter’s affirmative decision, the court concludes that Dinter should have foreseen that his decision would be relied on by Simon and her patient, and this decision could harm Simon’s patient if made carelessly.”

Response from the medical community

In response to the ruling, the MMA stated:

“The Court’s decision to rely on a broader legal theory of ‘foreseeability’ represents a troubling change that puts Minnesota in the minority of states that do not require the existence of a physician-patient relationship for a malpractice action. This change may expose physicians and other health professionals to malpractice risk in a variety of actions that were previously protected, including unbilled consultations. Although the ruling puts Minnesota physicians in uncertain legal territory, it does not change the underlying duty that physicians have to their patients and, more generally, to maintain a professional and ethical medical practice.”

Looking forward, the MMA is creating resources to help physicians understand the potential legal risks following the Warren v. Dinter decision. The MMA is specifically looking at policy options to make sure that physicians are able to collaborate with peers and offer the best care possible to their patients.

Future implications

Now that “foreseeability of harm” will likely play into the decision of whether to practice “curbside consultations,” experts fear an unsettling effect among physicians. Physicians are notoriously risk averse, and if informal conversations create a duty—and, therefore, possible liability—then many physicians may now choose not to share advice or insights with colleagues without a promise of security from any legal ramifications. This chilling effect could end up adversely impacting medical decision-making practices, consequently hurting patient care and raising healthcare costs.

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