So, without actually seeing the medical record, it's hard for any outsider to have a meaningful insight into this case. I'll make a few generalizations, though, based on what I can glean from the article:

1. "Admission to the hospital" means "being put in a bed upstairs to receive treatment that can only be given in a hospital over the course of days." For a hospitalist to admit, the patient bypasses the emergency room, bypasses an initial ED workup, and passes directly into that physician's care. I know don't know any hospitalists that will take a patient as described in this article for a direct admission. The patient either belongs in an outpatient management, or should be coming through the ED for initial speedy (relative to inpatient!) workup and therapy. Direct-to-inpatient admission is for hospital-only therapy that isn't an emergency - e.g., you need a week-long IV infusion of a medication. You'd get admitted directly to that physician's service, get brought in, get your infusion going, etc. Non-emergent.

When a physician "refuses to admit" from outpatient clinic it does not mean "this patient can't come to the hospital". It means they don't avoid the ED and go straight to the slower inpatient care process. This patient may very well have needed some IV abx for six hours and then get sent home. That's not the hospitalist's call, and not what the hospitalist is described as doing in this article. Which makes sense, because /that's not how any of this works/.

This article's suggestion that a hospitalist saying "I'm not admitting this patient" equals "this patient can't come to the hospital and should just go home" is inaccurate and sloppy reporting. It's just wrong. And you know what? The NP in this story knew that.

"However, rather than send Warren straight to the ER of the Fairview Range Medical Center, Simon called the hospital “to seek Warren’s admission." " The NP did the wrong thing, and the hospitalist saying No to the wrong thing is getting blamed.

"If you have the power to decide on the treatment and hospital admission of a patient you have a patient-doctor relationship." is incorrect. This doctor did not have power to stop this patient from coming to the ED and getting ED care, which is the route the NP should have sent them through and the only route for getting emergency management in the hospital. The NP asked for a thing that does not happen and is not needed for the patient to get the right care and is in fact the Wrong care, and now it's being described as though the hospitalist had the power to say "go home or get hospital care." That's just incorrect.

2. Episodes of diabetic worsening can cause a white count, particularly if the patient is trending towards acidosis. The article calls this as "flaky diagnosis," and says "this is the first the NP heard of it," implying that this was untrue. It was not untrue. Though this certainly does sound like an infection, I imagine the actual conversation went "can I immediately admit this patient with this white count?" and the doc went, "this isn't that bad a white count, part of it is probably from the diabetes, also, no, I don't do admits from community, no."

3. NP's are supposed to practice under physician supervision. "Still concerned about Ms. Warren’s condition, Simon then spoke to Dr. Jan Baldwin, her “collaborating physician” at the Essentia clinic." So, she did an end-run around the normal admission process, and got bounced both for (a) possibly over-stating the white count?, and (b) ...because the route for this patient getting admitted is through the ED, not by calling not her supervising physician. She then went to her actual supervising physician, who apparently said the same thing about this patient. The article includes the line "but they didn't examine the patient." Yes, because they relied on the NP to furnish the physical exam details; they went to the EMR to check out all the lab values and vitals (because if they didn't, there'd be no public suit; the malpractice insurer would be running straight to a very nice settlement.) The very-neutral and well-researched article refers to this fact as "amazing." It's standard practice. (a) If you can't rely on an NP to convey the results of a physical exam, they shouldn't be allowed to have anything resembling independent practice rights. (b) you're legally allowed to rely on them to convey physical exam, and (c) there is no statement that anything in the physical exam is what changed the clinical picture here.

So, two independent physicians looked at this patient's labs and didn't see an out-of-control infection - the only clinical counterpoint we're seeing is from an NP who apparently didn't know about the "every med student knows about this" fact that diabetes can drive a white count, and less controlled diabetes drives it more.

I actually do think that there were a couple of fuck-ups here:
(a) The NP should have sent the patient to the ED if they were convinced this patient was fucked up. Period.

(b) The NP should not have called the hospitalist directly. Period. It's a red-herring to the entire event. The only question is "can I manage this outpatient or do I send them to the ED?" not "can I manage this outpatient or do I send them to inpatient where their work-up and treatment will be delayed 12-24 hours at a minimum, if inpatient would even take this patient bypassing the ED, which they won't, so why the fuck am I even calling them?"

(c) Diabetic with a fever and a white count and out-of-control sugar can be poorly controlled diabetes. Or an incipient DKA. Or septic. Or having a heart attack. The supervising physician who directed outpatient management - not the hospitalist - made the probably-wrong call by sending this patient home. They should have directed to the patient to the ED. I can't say this more strongly without seeing the actual medical record, but if malpractice happened, it happened at this step. The "if" is because if the white count was only a little up, and the NP said, "well, they don't look septic," and the patient reports poor compliance with their diabetes meds, ... well, it would be reasonable to say, "eh, diabetes." I still would've sent to the ED, but this isn't my jam, so I could be wrong.