A question for other clinicians

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cwbullet

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Can a physician be commanded to run a medical test? For example, can the court or even the hospital CEO order a physician to run a laboratory or radiology exam?
 

heada

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I'm not a clinician but as a lay person, I thought a physician could refuse such things if they felt it was in the best interest of the patient. You're in a different position than most but in general I thought no one could force anyone to perform an act that they felt went contrary to their ethics. There could be repercussions from not doing so such as getting fired. Military is different of course.

With the exception of military, being forced to perform against your will is slavery, no?
 

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It think is of questionable ethic for sure.
 

seth_cooper

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Hell no!

That would be against the 13th amendment.

The only exception might be in the military. But I doubt it.

I'm in a different field (dentistry).
 

NateB

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That is a good question. Our hospital policies exempt us from participating with procedures we have ethical objections over and not be fired. I'm not sure if the physicians have the same rights, but I would assume they do. The intention is to not force someone to participate in an abortion, but that isn't something that has actually come up, nor is that a procedure that would be done at our hospital except in a rare emergency.

Other situations do come up and get discussed on a case by case basis. I have been ordered to terminally wean a ward of the state, but this was done in consult with a team of experts.

I would think if am individual physician refused to order a test, the hospital CEO would just ask someone else until they got what they wanted.
 

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Hell no!

That would be against the 13th amendment.

The only exception might be in the military. But I doubt it.

I'm in a different field (dentistry).
I concur. Not sure about the 13th. I would agree things are different in the military except for one thing. I pay for my own license. That makes it my license and not Uncle Sam's. I can't be ordered how to use but I can be order to assess and evaluate a patient. I cannot be ordered to treat btu will be judged based on my peers (standard of care).
 

Cl(VII)

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I concur. Not sure about the 13th. I would agree things are different in the military except for one thing. I pay for my own license. That makes it my license and not Uncle Sam's. I can't be ordered how to use but I can be order to assess and evaluate a patient. I cannot be ordered to treat btu will be judged based on my peers (standard of care).
I did not know that distinction existed, but it makes sense. Out of curiosity, and feel free to decline to answer, do you have to carry your own malpractice insurance for the same reason?
 
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Marc_G

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I can see situations where a doctor or other medical professional could be compelled to perform specific services potentially including tests against their will; for example if the doctor's religion conflicted with the service needed. Maybe the doctor doesn't believe in MRI or feels looking inside the human body desecrates it or something. Or the example of the pharmacist who doesn't want to dispense birth control.

If we take religious edge cases (that are real, but rare in practice) out of it I would expect it comes down to welfare of the patient being paramount.

Sorry, I just noticed you were looking for answers from clinicians and I'm not one (thank goodness!). For what it's worth if you found yourself in a bind, I would bet 100-to-1 odds on whatever you decided, as being right.
 

cwbullet

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I did not know that distinction existed, but it makes sense. Out of curiosity, and feel free to decline to answer, do you have to carry your own malpractice insurance for the same reason?
Malpractice insurance is not a requirement to practice medicine. Slightly different. Only in rare states is it required.
 

Cl(VII)

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The military, states, and many hospitals provide it as a means of compensation and to pay less.
I was going to just use the emojis to respond, but I couldn’t figure out which one applies. Glad I went the medical research route, and not the medical delivery route. Physician is a weird gig, particularly this year. Good on you and your kind, Chuck.
 

augendoc

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The original question needs clarification. Most physicians do not run the test or take the X-ray. There are technicians for that. The physician orders the test and interprets the results.

Not all situations require a physician order for a test. For example, in most states as a condition for getting your drivers license you give the state permission to determine your blood alcohol level, no physician involved.

In most states, there is a proscription against the corporate practice of medicine. For example, a large hospital chain’s CEO or Board of Directors cannot across the board order that an MRI be done on every patient. Doing so would be great for their bottom line and many hospitals or hospital medical groups have hidden internal pressures to encourage their docs to do the ordering. But in the end it’s the individual physician who is required to use their medical judgment as to whether to order a test. In most states there are laws that mandate physician reporting of a condition to a governing authority (TB, COVID-19, sexually transmitted diseases, measels, plague, hantavirus, for example) but that‘s not the same thing.

Most medical tests require a physician order for good reason. This is because a test result out of context is meaningless. The results need to be interpreted in light of the patient’s situation and that takes a physician. It takes training, experience and physician judgment to determine if the test results makes sense, if they are outside the range of normal but still normal for the patient in question, whether the test result may be a false positive or negative, and what the physician and patient are then going to do with the information.

Also, some tests have risks and someone needs to understand the risk-benefit ratio and explain that to the patient and in some cases refuse to order a test based on that.

Finally, results can have consequences. The test may miss something, or the test may be abnormal enough that the medical establishment pursues something that isnt there and that pursuit can lead to more tests with their own problems. Every physician has seen this and some of these pursuits can be doozies. Don’t ask...

Some tests have been deemed by governing authorities as not requiring a physician order, like some of the COVID-19 tests, so in theory the general public can just drive up and get one. This may seem like a great idea to the medically uninformed, but in the COVID-19 situation there are numerous tests of varying quality with differing sensitivities and specificities and in many cases a single result whether positive or negative means jack **** out of context.

So, sorry for the long-winded answer. It all comes down to physician judgment. No one can order the physician to order a test. But if the patient has a compelling medical reason to have the test, the physician needs to have a more compelling reason not to order the test. If not ordering the test would be outside the standard of care, the physician better have a plausible argument to submit to a jury.

If on the other hand the physician has a religious reason to not want to do the test, ethics would require the physician to either refer the patient to someone who will order and interpret the test, or to explain their reasoning to the patient so that the patient could make their own decision whether to seek another physician.

It’s complicated...
 

NateB

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The original question needs clarification. Most physicians do not run the test or take the X-ray. There are technicians for that. The physician orders the test and interprets the results.
For a few tests, that technician could be me. I would hope that our doctors wouldn't be forced to order a test or procedure that they didn't think would benefit the patient or were ethically opposed to. As a technician level employee, do I have the same right to not fulfill orders I might object to?

Honestly, this hasn't come up in 17 years. I have done procedures I wouldn't want done on myself or family in those situations, but I work for my patients and their families and not my personal thoughts.
Not all situations require a physician order for a test. For example, in most states as a condition for getting your drivers license you give the state permission to determine your blood alcohol level, no physician involved.
I have seen court orders to draw a BAC and drug screen. Our physician still inputs the order in the computer or verbalizes the order for the draw before we are allowed to do it. Although these are standard tests for trauma patients, the doc might just call out to draw a "trauma panel" and we know what that means per protocol. PD needs the test done a certain way for a court case, which is where the court order generally comes in.
 

BABAR

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As a Radiologist, in most cases a diagnostic exam has already been performed before we see it, once it’s done we are required to report it. But for imaging or image guided procedures PERFORMED BY the Radiologist (angiograms, barium studies, CT guided biopsies for example), if I don’t think it is indicated (risks outweigh benefits to the PATIENT) I won’t do it. We also TRY (With limited success) to have our techs refer docs to us when they order exams that are clearly not indicated.

Physician’s primary obligation is (or at least SHOULD BE) to the patient, and always under the mantra, “First do no harm.” Both laboratory tests and imaging studies CAN cause harm, in some cases because the results of on lab or x-ray study may start a cascade of OTHER studies generating patient anxiety, wasting patient time and money, and possibly leading to biopsies or endoscopies or catheter angiograms where there is a very small but real risk of injury or death, all on a path started by a lab or X-ray that never should have been ordered in the first place.

Good example, the old lady who swallowed a fly....


I don’t think physicians are required to obey commands to run certain tests. But employers may REQUIRE those tests for beginning or continuing their employment
 

NateB

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Something else just popped into my head. 10 or 11 years ago when I was working on a 911 ambulance, a local ER doc told us EVERY patient we brought in needed to have already had an IV with a saline lock, glucose check, and a lead II strip from the monitor. I told them no, because I'm not performing procedures I don't think the patient needs and left it at that. I ran the issue by my medical director and he certainly didn't want us doing unnecessary procedures if they weren't warranted under his medical license. I see no need to stick needle in someone in the field unless I am going to give fluids, drugs, or think that I may need to in the immediate future. I can be clean about it, but there is certainly a higher risk of infection doing these things in someone's living room or while moving down the road than sitting in an ER or hospital room.
 

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When I was a resident, surgeons would refuse consults if certain procedures were not performed even if not warranted. That day has changed, thankfully.
 

boatgeek

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In most states, there is a proscription against the corporate practice of medicine. For example, a large hospital chain’s CEO or Board of Directors cannot across the board order that an MRI be done on every patient. Doing so would be great for their bottom line and many hospitals or hospital medical groups have hidden internal pressures to encourage their docs to do the ordering. But in the end it’s the individual physician who is required to use their medical judgment as to whether to order a test. In most states there are laws that mandate physician reporting of a condition to a governing authority (TB, COVID-19, sexually transmitted diseases, measels, plague, hantavirus, for example) but that‘s not the same thing.
...
How does this relate to current corporate policies (in some places) that everyone who is coming in for treatment must have a COVID test? For example, my niece had to be in town for two extra days last month because she needed a COVID test before going in for a cancer treatment. Other hospitals in that system test all incoming patients, and I think Chuck mentioned that policy in one of his posts.
 

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How does this relate to current corporate policies (in some places) that everyone who is coming in for treatment must have a COVID test? For example, my niece had to be in town for two extra days last month because she needed a COVID test before going in for a cancer treatment. Other hospitals in that system test all incoming patients, and I think Chuck mentioned that policy in one of his posts.
The PCR test is terrible for this. It has a 30% false positive rate. It absolutely does not rule out COVID. This type of testing is about buying down risk prior to a risky procedure or treatment. There is still a 30% chance of the patient being positive, but delaying the treatment may be a lower risk than treating a patient that has COVID.
 

Gus

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Can a physician be commanded to run a medical test? For example, can the court or even the hospital CEO order a physician to run a laboratory or radiology exam?
CW,

The answer to your question is an unequivocal "no." As an ER doctor, I am often presented with patients in the company of police officers for an alcohol or drug check. If the patient does not consent, we are ABSOLUTELY not allowed to do the tests. There are criminal penalties associated with refusing the tests, but I ABSOLUTELY may not test anyone who refuses.

We also occasionally get someone sent in by their workplace, including our own, for sobriety checks. Again, if the patient refuses, no test.

What happens between you and your employer, or between you and the police, for refusing a test has nothing to do with me. As for employers wanting COVID tests on employees, again, I can only do that with patient consent.

Very simple, very straightforward.

By the way, thanks for all the great info you've been providing folks here on the forum. I'm sure it turned out to be a bigger task than you bargained for at the beginning but, clearly, a large number of people have gotten huge benefit from it. That's REAL doctoring my friend! Kind of what we all thought we'd do when we were applying to medical school. Kudos, CW!
 

cwbullet

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CW,

The answer to your question is an unequivocal "no." As an ER doctor, I am often presented with patients in the company of police officers for an alcohol or drug check. If the patient does not consent, we are ABSOLUTELY not allowed to do the tests. There are criminal penalties associated with refusing the tests, but I ABSOLUTELY may not test anyone who refuses.

We also occasionally get someone sent in by their workplace, including our own, for sobriety checks. Again, if the patient refuses, no test.

What happens between you and your employer, or between you and the police, for refusing a test has nothing to do with me. As for employers wanting COVID tests on employees, again, I can only do that with patient consent.

Very simple, very straightforward.

By the way, thanks for all the great info you've been providing folks here on the forum. I'm sure it turned out to be a bigger task than you bargained for at the beginning but, clearly, a large number of people have gotten huge benefit from it. That's REAL doctoring my friend! Kind of what we all thought we'd do when we were applying to medical school. Kudos, CW!
I knew the answer. I was just using each fo you to shape my discussion with local folks who are trying. Your answer is the best I seen so far.
 

boatgeek

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CW,

The answer to your question is an unequivocal "no." As an ER doctor, I am often presented with patients in the company of police officers for an alcohol or drug check. If the patient does not consent, we are ABSOLUTELY not allowed to do the tests. There are criminal penalties associated with refusing the tests, but I ABSOLUTELY may not test anyone who refuses.

We also occasionally get someone sent in by their workplace, including our own, for sobriety checks. Again, if the patient refuses, no test.

What happens between you and your employer, or between you and the police, for refusing a test has nothing to do with me. As for employers wanting COVID tests on employees, again, I can only do that with patient consent.

Very simple, very straightforward.

By the way, thanks for all the great info you've been providing folks here on the forum. I'm sure it turned out to be a bigger task than you bargained for at the beginning but, clearly, a large number of people have gotten huge benefit from it. That's REAL doctoring my friend! Kind of what we all thought we'd do when we were applying to medical school. Kudos, CW!
Because looking at loopholes is half of what I do in my day job, I have a couple of hypotheticals.
#1: You're working in a hospital that has a "test all patients for COVID when they walk in the door" policy. Someone arrives at the ER door with a life-threatening injury but refuses the COVID test. They probably wouldn't survive transport to the next hospital over. You have three mutually-exclusive requirements: don't test without consent, test all incoming patients, don't refuse treatment to a patient who needs it. Which one of those breaks? Does it matter if the hospital is military, publicly owned, or privately owned?

#2: Same basic scenario, but the patient is unconscious and can't give consent. Can you administer the COVID test without consent?

I'm pretty sure I know the answer to #1, but consent requirements for #2 are a little fuzzier for me.

Again, thank you to all of the medical professionals here (and out there). I really appreciate your perspective and the work you do whether there's a pandemic or not.
 

NateB

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#2 is implied consent. It is assumed that someone unable to consent for care, would consent if they were able to. We try to figure out the patients's wishes with the limited information available to us in the time it takes to make these decisions. Flawed, yes, but you err on the side of saving a life.

#1 EMTALA laws and human decency require us to stabilize life threatening conditions and arrange transport to a suitable hospital when someone arrives at an ED. A Covid test would / should be deferred until the patient was more stable.
 

cwbullet

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#2 is implied consent. It is assumed that someone unable to consent for care, would consent if they were able to. We try to figure out the patients's wishes with the limited information available to us in the time it takes to make these decisions. Flawed, yes, but you err on the side of saving a life.

#1 EMTALA laws and human decency require us to stabilize life threatening conditions and arrange transport to a suitable hospital when someone arrives at an ED. A Covid test would / should be deferred until the patient was more stable.
That sums it up.
 
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