Ethical: Physician family members of patient place/change orders.

This happened today, and I just want to get some other opinions - maybe I'm making this out to more than it is. Sorry for the length.

**Backstory:

Patient PMH of AFib, COPD, PNA, CHF, CAD/PVD; admitted for severe anemia and COPD exac, poss CHF exac, r/o GIB.**

Today: Floated so this is on the stepdown unit/not in the ICU. Right around 8 a.m., I'm about to call the attending about an elevated troponin when I see the pulmo consult and echo cancelled and meds being ordered by a physician NOT on this patient's case. I was told it was the patient's family member. Apparently this family-member-physician is also a BMOC and an intensivist. Let's call him Dr. Critical. When Dr. Attending returned call, I ran all Dr. Critical's orders by him. He said ok to changing cardio consults, but to reconsult pulmo and order the echo. I did so. An hour later, the consult was cancelled.

I then see Dr. Critical's wife, who is also a physician. She follows me into the supply room and asks me about the patient's Hgb level. In the interest of professionalism - and she was family - I gave it to her. Ten minutes later she said she called a GI doc and he would be coming today. I informed her there was no order. She said, "my husband or I will put it in." Again, NEITHER of them are on the case.

This is when I go to the charge and update her on what's going on. We discuss it and I firmly stand my ground that this is highly irregular, unethical, and problematic for patient care. I went on - Who am I calling for orders?, Who gets critical lab calls?, What about all these cancelled orders? I've dealt with this before, and it usually gets nipped in the bud quickly. However, it seemed like the first time anyone has dealt with this before [at this hospital].

Dr. Attending rounded on the floor. I told him that the echo was discontinued - he said to order it again. I told him about all these orders and conflicting things and I asked him to at the very least consult Dr. Critical if he was going to put orders in. He walked away saying..."uh, i'm going to go discharge this other patient."

An hour or so later, the house supervisor comes up. She is pretty dismissive about the whole thing, but her eyes opened wide when I said, "I'm concerned about the patient's safety...possible adverse event in the making...this is how patients get forgotten about..." She said the best thing is for me to call Dr. Attending everytime Dr. Critical places an order and obtain approval.

My response: "I'm sorry, but with all due respect, I refuse. Running a one-time order to check is fine; getting approval for a med from cardio or a test by nephro is one thing; but checking every single order is inappropriate. Dr. Critical is 1) not on record on this case, 2) he is a family member of this patient, and 3) he repeatedly discontinues the attending physician's orders despite repeated entries - e.g. we ordered the echo four times. Dr. Attending needs to either put Dr. Critical on consult, transfer attending duties, or put in orders on Dr. Critical's behalf. This needs to be a physician-to-physician issue, and risk management needs to be involved.

The super looked at me like I had five heads.

This continued for a few hours. Cardiology came (not the guy Dr. Attending consulted but the one Dr. Critical consulted), asked if there was an echo. I said, yes, Dr. Attending ordered one." He said, 'ok.' Well, an hour or so later, again, the echo was discontinued by Dr. Critical - who is still not on the case. Then, Dr. Critical wanted q6h H/H draws; Dr. Attending wanted to avoid any phlebotomized anemia (total of 3 tubes q 6h) and cancelled it. Dr. Critical re-entered the timed H/Hs.

Around 1 or 2 p.m., there was finally "consult to crit care med" placed by Dr. Attending. Within 10 minutes, there was a consult note by Dr. Critical. Stated the patient wasn't an ICU candidate to avoid transferring him to his unit. Said "will follow." Critical care following on a non-critical patient?

Fast forward - I finally got all this sorted out around 6 p.m., and I finally left the unit around 8:45 p.m. (so far behind with four other high-acuity patients).

So, I ask... am I wrong in standing ground that:

1. This whole situation is a big ethics violation - physicians caring/ordering for family members,
2. Doctors seeing/rounding/ordering on patients there is no consult for,
3. Considering the above - having this "order juggling" going on via computer - without communication to physician or RN.

[AMA Code of Medical Ethics: Self-treatment and treatment of family members] (http://www.ama-assn.org/ama/pub/physician-resources/medical-ethics/code-medical-ethics/opinion819.page?)

Physicians generally should not treat themselves or members of their immediate families. In emergency settings or isolated settings where there is no other qualified physician available, physicians should not hesitate to treat themselves or family members until another physician becomes available. (Not an emergency situation in this case)

Sidenote: Also, I'm not a billing expert (correct me if I'm wrong, please), but when I was rounding with physicians, I was under the impression that if you see a patient, you charge. If you put in a rounding note or consult, you can charge. If you place an order - especially several orders - you can charge, and the hospital can charge as well. So Dr. Critical can be charging Medicare for seeing his family member?

[Medicare Carriers Manual - Charges imposed by immediate relatives...] (http://www.sccma-mcms.org/Portals/19/assets/docs/Physician-treating-family-member.pdf)

Do not pay under Part A or Part B of Medicare for expenses, which constitute charges by immediate relatives of the beneficiary or by members of his/her household. The intent of this exclusion is to bar Medicare payment for items and services furnished by physicians or suppliers, which would ordinarily be furnished gratuitously because of the relationship of the beneficiary to the person imposing the charge.

As I finish writing this, it doesn't seem to really convey everything that went on today, but I'm sure you get the gist of it.

TL;DR. Doctor barged in and placed lots of orders on his family member without consult, consult was a shoestring order; attending doc backed down; tons of orders confused; ethics problem?

Edit: added in that this is NOT in the ICU, it's on the stepdown unit. I think this makes it more apparent that Dr Critical was just nosing in.