Primary Care: A Claims and Risk Reduction Workshop

Primary care specialties have generally been considered at low risk for malpractice liability. Although this continues to be relatively true, there has been a significant increase in the frequency of suits against primary care physicians. Consequently, The Doctors Company held a Primary Care Risk Reduction Workshop. Before describing the results, it is worthwhile to review trends identified by previous panels.

Approximately 35 percent of the cases reviewed in this workshop involved delays in diagnosis. Late diagnosis of cancer was by far the most common of these. Within that category, mismanagement of breast cancer was the largest subgroup. The most frequent error was allowing a negative mammogram to delay biopsy of a clinically suspicious lesion. Incomplete evaluation of iron deficiency anemia that led to a delayed diagnosis of gastrointestinal malignancy was also common. Other conditions often found in cases of delayed diagnosis involved chest and abdominal pain. Index examples in that group included delayed diagnosis of either appendicitis or abdominal aortic aneurysm or of myocardial infarction—in which case the patient, complaining of chest pain, had been reassured of being in good health.

Approximately 30 percent of the cases involved adverse outcomes of disease management. Surprisingly, inadequate treatment of diabetes mellitus was the most common cause of suit. Typically, these cases involved either fatal outcome from diabetic ketoacidosis or amputation caused by a lack of appropriate vigor in treating peripheral vascular disease or lower extremity infections. Drug reactions were the major subgrouping in these cases, with complications from prednisone or Coumadin most frequent. Both medications require close monitoring, and the panel often found that the indications for using these potent drugs were insufficient to justify the risks. Allergic drug reactions were also a common cause of suit. Such cases were nearly impossible to defend when allergy had been previously documented.

The remaining cases fell into categories that typically included problems with documentation, informed consent, communication (especially between doctors and nurses), compliance, and patient anger.

Results of the panel should be viewed against this background, with particular attention given to the more recent trends.

Diagnostic Error

The first case involved a 30-year-old woman who presented with urinary frequency. Pelvic examination was performed, and a yeast infection, acute cervicitis, and vaginitis were found. Appropriate treatment was instituted, and the patient was told to return in two weeks for examination and a Pap smear. At that time, the defendant family practitioner noted severe endocervicitis.

A Pap smear was taken, and a follow-up appointment was scheduled for two weeks later. The Pap smear was Class III, but the lab report was filed in the patient’s chart before being seen by the physician. The reference laboratory sent a reminder notice to the physician’s office that the Pap smear was abnormal. The billing person at the physician’s office was aware that the patient had refused to pay her invoice and sent the patient a copy of the notice about her abnormal Pap smear along with a billing reminder. The patient discarded the letter without reading it. A similar notice was sent to the patient five months later without response. It was not until one year later, when the patient’s mother, also a patient of the same doctor, inquired about the health of her daughter, that the abnormal test was readdressed.

A review of the chart at that time revealed the Pap smear report. At re-examination, the patient was found to have a fungating carcinoma of the cervix. She died a little more than one year later. While the patient clearly bore some of the responsibility in this case, part of the responsibility belonged to the doctor’s office. Test results should never be filed in a patient’s chart without being initialed by the physician. Billing disputes must be separated from patient care. Juries will not be sympathetic to the argument that a woman died of cervical cancer because she did not pay for her Pap smear. Moreover, the billing person should have brought the patient’s dissatisfaction directly to the attention of the physician.

Another case involved delayed diagnosis of a cervical fracture. A 20-year-old patient was the driver of a car that collided with a horse. X-rays of her cervical spine were interpreted as negative by the radiologist, and it was not until five days later that the patient was re-evaluated for continued neck strain. At that time, an orthopedic consultant performed a CAT scan that demonstrated a fracture of the cervical spine. The patient’s suit alleged that she sustained a disc herniation as a result of a delay in diagnosis of the cervical spine fracture. In this case, the defense should be relatively straightforward. The primary care physician performed and documented a careful examination. He was entirely justified in relying on x-ray interpretation by the radiologist, and follow-up mechanisms were appropriate.

The following case would be much more difficult to defend. A 67-year-old man who complained of pain in the left groin and testicle was examined by his family practitioner. An easily reducible left inguinal hernia was noted, and a clinical diagnosis of epididymitis was also made. There was no documentation of physical findings suggesting that condition, however. Tetracycline and Tylenol with codeine were prescribed.

At 3:00 A.M. the following morning, the patient was admitted to the hospital emergency room (ER). The physician was contacted by the ER nurse who reported the patient’s complaints of repeated emesis and left groin pain. Over the phone, the physician prescribed Demerol and Vistaril, but the doctor did not examine the patient. One-and-a-half hours later, the nurse called the doctor again to request hospital admission because of persistent symptoms. Although the patient was admitted, he was not examined until 8:00 A.M. the following morning, when he was in shock. The patient died later that day following emergency surgery at another hospital; he had been found to have a ruptured abdominal aortic aneurysm. Given the patient’s deteriorating condition, it is difficult to defend failure of the attending physician to re-evaluate his initial diagnostic impression. A personality conflict between the emergency room nurse and the attending physician was a factor in this case. While this may have influenced the doctor’s judgment, it would hardly be a defense for his inaction.

Delay in the diagnosis of meningitis can be devastating. The symptoms can be relatively subtle in children younger than one year old.

Doctors evaluating infants who have high fevers must maintain a high index of suspicion for underlying meningitis. One case involved an infant with a temperature of 104 degrees. The child was active and crying. Initial examination revealed no neck stiffness or bulging of the fontanelles. It was not until the following day that the child had a seizure and was hospitalized. Meningitis was diagnosed, but by then, the patient had significant neurologic deficits—including deafness and right hemiparesis. Although meningitis was not the most likely diagnosis at the time of the physician’s initial contact with the patient, the very poor records available in this case, the critical importance of full evaluation of fever in infants, and the serious deficits suffered by the patient would make defense difficult.

The litigation crisis in obstetrical care is well known, and family practitioners who perform deliveries have not been spared. The panel reviewed a case of misdiagnosing appendicitis in a 32-year-old woman, gravida III, para III, whose initial prenatal course had been uncomplicated. She presented with acute complaints of nausea, vomiting, and right-sided pelvic pain. Her ruptured appendix was detected the following day, and two days later an emergency C-section was performed that produced a severely impaired infant. While the panel recognized the difficulties of diagnosis in this setting, the case review emphasized the sometimes illusory distinction between uncomplicated and complicated obstetrics.

Adverse Management Outcomes

As expected, several review cases involved management of diabetes. The first involved a 70-year-old woman who saw her physician to complain of pain and swelling in her right foot. A diagnosis of gout was made and treatment was instituted. Two weeks after that initial visit, the patient was found to have a gangrenous right first toe that ultimately led to a below-the-knee amputation of the right leg. The second case involved a 35-year-old juvenile onset diabetic who was seen by a primary care physician on call for the patient’s regular doctor. The patient’s complaints included peripheral edema, inability to urinate, dyspnea, abdominal pain, and lethargy. She felt she needed hospitalization, but the physician refused, choosing instead to treat her with outpatient diuretics. The patient was hospitalized the following day with acute respiratory failure that was secondary to pulmonary edema, renal failure, and diabetic ketoacidosis. The renal failure was irreversible, and the patient required a kidney transplant.

Another case illustrated how routine procedures occasionally have devastating outcomes. A 50- year-old patient came to her long-standing physician with acute hemorrhoidal pain. He performed a rubber-band ligation. The patient developed excruciating pain and purulent drainage in the surgical area. Ultimately, she was found to have a necrotizing cellulitis and required a long hospitalization for a diverting colostomy and intravenous antibiotics. The residual deficits included poor anal sphincter tone and extensive scarring on the buttocks and perineum. The panel severely criticized the doctor in this case for inadequate informed consent and for failure to instruct the patient on appropriate postoperative care and follow up.

Other Issues

It is important to note that six of the 16 cases reviewed by the panel reflected serious problems in documentation. In one, the records were so illegible they were virtually useless. In another, the records may have been altered after the fact, which would have made the case absolutely indefensible. The panel was impressed by the importance of physician preparation for deposition. Defense counsel has a significant role to play in this area, but doctors should be prepared to review the facts of the case carefully and to educate themselves and their attorneys about the underlying anatomy, physiology, and pathology. Doctors should also understand the principles of effective testimony.

Conclusion

Risk management in primary care continues to involve sound principles of patient care, which can be summarized as:

• Good documentation
• Careful informed consent
• Open communication between doctor and patient, between doctor and nurse, and between doctors
• Attention to the delicate balance of a patient’s rights vs. the doctor’s responsibilities. While patients are free to refuse interventions, physicians are held responsible for acts of omission, unless it can be shown that they fully informed the patient of the consequences of such decisions.
• Defusing patient anger. Patients rarely sue unless they are angry at a doctor. Often, simple acts of personal attentiveness and courtesy prevent large lawsuits.

J3202 5/00

Updated: May 2000
Originally published: April 1990