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 WHAT’S THE VERDICT?

Medical Judgments and Settlements

Editor-in-Chief

  Delayed referral ends in (too) late diagnosis of colon cancer

CONSTIPATION AND ABDOMINAL PAIN prompted a 45-year-old woman to consult her primary care physician, who recommended a change in diet. Two months later, the patient returned to the doctor because her symptoms hadn’t resolved, but admitted that she hadn’t altered her diet. The doctor repeated her recommendation for dietary change.

A month later, when the symptoms had worsened, the physician referred the woman to a gastroenterologist, who performed a colonoscopy. The colonoscopy revealed a large mass in the colon, which was diagnosed as stage IV cancer. The woman ultimately died.

PLAINTIFF’S CLAIM The doctor was negligent in failing to diagnose the cancer promptly.

THE DEFENSE The patient was treated for the complaints she presented with at each visit, and a referral wasn’t warranted until it was given.

VERDICT $420,000 New York verdict.

COMMENT I shudder when I read cases that could reflect my own practice patterns. How many patients with abdominal pain do we temporize? And the delay in diagnosis was only a few months!

  Student in “excellent” health collapses on basketball court

The summer before he was to start college, an 18-year-old student went to an internist for a physical exam and asked the physician to complete a form that the college required. The physician documented a “slight systolic murmur” on the form, followed by a question mark. The physical was otherwise unremarkable, and the physician signed the form, indicating that the young man was in “excellent” health and fit to participate in all college activities without restrictions.

Nearly 4 years later, the student—then a senior and a member of the college basketball team—collapsed and died during a game. The cause of death: sudden cardiac death related to hypertrophic cardiomyopathy (HCM).

PLAINTIFF’S CLAIM The physician found a slight systolic murmur—a condition often associated with HCM—that should have prompted her to order further tests. Additional testing would have resulted in an HCM diagnosis.

THE DEFENSE The doctor did order an electrocardiogram, but the patient failed to keep the appointment. During the 3½ years after the exam, 5 other health care providers cleared the young man for college athletics.

VERDICT $1.6 million Massachusetts jury award.

COMMENT Sometimes seemingly innocuous findings can signify serious problems. Lack of closing the loop on documentation and follow-up remains a common denominator in malpractice settlements.

Sources: MoreLaw Lexapedia. Available at: http://www.morelaw.com/verdicts/case.asp?n=&s=MA&d=43384. Accessed May 11, 2010; Hypertrophic Cardiomyopathy Association correspondence.

  Abnormal EKG with no follow-up, concludes with fatal MI

A 53-YEAR-OLD MAN WITH A HISTORY OF HEART DISEASE and cardiac symptoms went to his family physician of many years for a physical examination. The physician performed an electrocardiogram (EKG), which was normal, but the patient reported occasional chest pain. His physician referred him to a cardiologist for further evaluation. The cardiologist performed a stress test, which was normal.

Three years later, the patient had another physical exam and EKG. Although he reported no chest pain at this exam, he did mention heart palpitations, flutters, and skips. A computer reading revealed that the EKG was abnormal, with a possible inferior infarction. The patient’s physician nevertheless decided against a further work-up and did not refer him to a cardiologist.

Less than a month later, the man’s wife found him dead in bed. The death certificate cited myocardial infarction as the cause of death.

PLAINTIFF’S CLAIM No information about the plaintiff’s claim is available.

THE DEFENSE No information about the defense is available.

VERDICT $900,000 Virginia settlement.

COMMENT When faced with evidence of cardiac ischemia, prompt attention is indicated. Enough said.

  Suicide attempt blamed on improper med management

A MAN WITH OBSESSIVE-COMPULSIVE DISORDER was prescribed fluoxetine by his psychiatrist as part of treatment. After several years, the psychiatrist discontinued the medication; the patient subsequently developed selective serotonin reuptake inhibitor (SSRI) discontinuation syndrome, including depression and suicidal ideation. The patient tried, unsuccessfully, to kill himself with a shotgun and ended up facing criminal charges of reckless endangerment.

The patient was transferred to the care of another psychiatrist, who prescribed higher doses of fluoxetine. The suicidal ideation stopped, but the patient complained of ongoing, disabling depression and distress related to his suicide attempt.

PLAINTIFF’S CLAIM The doctor failed to manage the patient’s medication properly. Discontinuing fluoxetine is known to cause the symptoms the patient experienced.

THE DEFENSE The plaintiff had told the first psychiatrist that he wanted to discontinue fluoxetine and had failed to report any concerns related to stopping the drug. SSRI discontinuation syndrome is rare, and the symptoms are difficult to detect.

VERDICT $911,000 New York verdict.

COMMENT Although I would quibble with the label discontinuation syndrome (sounds more like recurrent major depressive disorder), it’s very important to monitor patients carefully when starting treatment with an antidepressant, during changes in therapy, and after discontinuing a drug.

The cases in this column are selected by the editors of THE JOURNAL OF FAMILY PRACTICE from Medical Malpractice: Verdicts, Settlements & Experts, with permission of the editor, Lewis Laska (www.verdictslaska.com). The information about the cases presented here is sometimes incomplete; pertinent details of a given situation may therefore be unavailable. Moreover, the cases may or may not have merit. Nevertheless, these cases represent the types of clinical situations that typically result in litigation.

The Journal of Family Practice ©2010 Quadrant HealthCom Inc.