Virtual Mentor. March 2001, Volume 3, Number 3.

Cases in Law and Ethics

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Responsibility of a "Virtual" Consultant

An ethical case describes the use of a virtual consultation with a pediatric psychiatrist when a 6-year-old boy seen in the emergency room has injuries suspected to be due to child abuse.

Kayhan Parsi, JD, PhD, and Audiey Kao, MD, PhD

eter, a six-year-old boy, was brought to the emergency room of a rural hospital complaining of severe pain in his right forearm. According to his mother, Peter was playing in the yard when he fell and landed hard on his right arm. Dr. Florence, who knows the family and has treated Peter occasionally in the past for bumps and bruises, performed an exam which revealed pain and mild swelling over his right forearm. No pain or loss in range of motion was noted in his elbow or wrist. An X-ray confirmed Dr. Florence's suspicion of a closed simple fracture of the right radius. 

During the course of the physical exam, Dr. Florence also found areas of bruising on Peter's back and legs. In addition, the X-ray revealed evidence of a previous fracture in his right arm. Despite claims by Peter's mother that he is "accident prone," Dr. Florence suspected abuse, and considering the seriousness of asserting such a cause of injury, wanted to consult a pediatrician who specialized in child abuse cases. Since this community hospital was in a fairly remote area, video conferencing equipment had recently been installed to facilitate consultation between local physicians and specialists not available in this rural community.  

Dr. Florence informed Peter's mother that he wanted her son to be seen by another physician through the means of the video equipment. Dr. Rhodes, a pediatric psychiatrist, was consulted because, if child abuse is suspected, immediate action including temporary state custody of the child may be required. As part of the virtual evaluation, Dr. Rhodes spoke with Peter and reviewed his X-rays. Given the limitations of the videoconferencing equipment, a physical exam including examination of the bruises could not be completed. Despite these technological limitations, Dr. Rhodes supported the initial concern about child abuse and recommended to Dr. Florence that Peter be taken into temporary state custody.  

1. Given the potential implications of suspected child abuse to the parents, should Dr. Florence, in making his decision, give Dr. Rhodes' recommendations the same weight as he would give a formal consultation?  

2. If Dr. Rhodes' recommendation is considered to be more of a "curbside" than a formal consultation, what features would be required as technology advances for a "virtual" evaluation to be considered a "regular" consultation?  

See Kuszler P. Telemedicine and the changing face of the doctor-patient relationship. and the AMA Code of Medical Ethics, Opinion 8.04, "Consultation."