Originally published December 2012
Patients often require concurrent care from more than one healthcare provider in hospitals and healthcare institutions. Patients of large clinics or other healthcare facilities may also be cared for by more than one physician. Identifying the most responsible physician (also known as the most responsible practitioner) and properly managing handovers of care can improve patient safety and reduce medico-legal risk for physicians.
What does it mean to be the most responsible physician?
The term most responsible physician (MRP) generally refers to the physician who has overall responsibility for directing and coordinating the care and management of an individual patient at a specific point in time. With expanding scopes of practice of other regulated health professionals, it is possible in some circumstances that a non-physician might also be considered the most responsible practitioner. At least one court has described the role of the MRP as follows:
... the practitioner most responsible for the in-hospital care of a particular patient. The MRP is responsible for writing and clarifying orders, and providing a plan of care, obtaining consultations as appropriate, coordinating care, as well as the discharge process. 1
The identity of who will act as MRP for a patient should be determined early, and based on the particular circumstances of each case. It should be clear in the patient's medical record which physician is designated as MRP. While typically the attending or admitting physician will be the MRP, this may not always be the case.
Physicians should be aware of any policies in their hospital or institution that might define the expectations of the MRP. Many hospitals, for example, have policies that set out the responsibilities of the MRP for managing patient care during regular or on-call coverage. Some hospital policies may use the terms attending or admitting physician to designate these types of responsibilities. Physicians should also be familiar with similar policies at clinics and other facilities where patient care may be shared with other professionals.
Who has responsibility?
In hospitals, healthcare institutions and facilities, more than one healthcare professional might owe a duty of care to an individual patient. For example, when referring a patient to a specialist, the MRP's original duty owed to the patient is effectively suspended: the MRP is generally not legally responsible for the care provided to the patient by the consultant, even though the MRP continues to be responsible for coordinating the patient's ongoing care.
There are, however, limitations on the extent to which an MRP may rely on the duty of others. In a recent case the standard of care of an MRP has been described as follows:
An MRP is not absolved of responsibility with respect to a medical condition simply because that medical problem is beyond the expertise of the MRP ... the MRP is responsible for a plan of care.2
When the MRP relinquishes the care of a patient to another physician, it is incumbent on the MRP to take reasonable steps regarding the patient's continued care until the new treating physician can assume caring for the patient. The MRP might also be expected to coordinate the care of a patient receiving concurrent treatment from different specialists, including for example, arranging other consults.
The MRP and the consultant should clarify their respective roles in ordering investigations and treatments and providing follow-up care. This information should be clearly documented in the medical record. It is helpful if patients and families are also made aware of who is most responsible for care at particular points in time and encouraged to raise their questions and concerns.
Responsibility for disclosing adverse events
If an adverse event (accident in Québec) occurs, the MRP should coordinate with the hospital, institution, or facility to determine when disclosure will be made to the patient, what information will be provided, and which person will initiate the discussion with the patient. In many cases, this responsibility falls on the physician most directly involved in the patient's care at the time, which may be the MRP. However, the MRP may not always be the appropriate person to lead the disclosure discussion, especially where system failure was identified or where another healthcare professional was involved.
Misunderstandings about who among the healthcare team is responsible for a patient's care may compromise that care, and may result in an adverse event and increased medico-legal risk. If the hospital or healthcare facility does not already have a policy or procedure in place outlining the expectations of the MRP, the physicians may want to establish protocols to help prevent potential breakdowns in the chain of communication both among healthcare team members and with the patient, and thereby help ensure that inconsistency or redundancy in care is avoided. Such protocols should address:
who is the MRP when a patient is admitted
procedures for the handover of care to another healthcare professional
ongoing responsibilities of the MRP, if any, to coordinate the patient's care
expectations among the healthcare team members for effective communication regarding patient care
the method (channel) for communicating information to the MRP
a system is in place to ensure the MRP knows that he or she is expected to take action
The aim is to have systems in place that make it reasonably clear to all involved in an individual patient's care which physician is responsible for the patient at any given time. When possible, care handovers should be face-to-face and focus on the transfer of key information such as the patient's diagnosis, the status of investigations and treatments, and anticipated possible problems and strategies to address them. As always, it is important to document relevant clinical information in the patient's medical record.
Manary v. Dr. Martin Strban, et al., 2011 ONSC 176