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Primary Care Panel

The Doctors Company convened a group of primary care physicians to review medical liability cases and discuss issues pertinent to primary care practices.

The seven cases selected for review were evaluated using criteria designed to provide consistency of review and to call attention to elements within the medical record that are critical for the defense of unfavorable outcomes. Our eight review elements were: 1) Physical examination: Does the medical record contain a complete physical examination? 2) Past medical history: Is the medical history documented? Are allergies included? Does the medical history include substance use/abuse and smoking? 3) Medications: Is there a medication list? Does it include any medications used chronically as well as current medications? 4) Diagnosis: Is a diagnosis documented? Is it consistent with current symptoms of the patient? 5) Prognosis: Is a prognosis documented? Does the medical record contain evidence of patient education related to the prognosis? 6) Treatment: Is a treatment plan documented? Is it consistent with the diagnosis? 7) Follow-up: Does the medical record document who is responsible for follow-up? Is it consistent with the diagnosis? 8) Diagnostic reports and consultations: Is there evidence that these have been reviewed by the physician?

Outcomes for the seven patients did not significantly vary: There were three deaths, three with brain damage or injury, and one with permanent nerve damage. Similarly, there were consistencies in the reviews that are noteworthy. Four of the seven cases were found to involve missed diagnoses, and three providers were found to have given inappropriate treatment. The physicians whose cases were brought to the panel consisted of six family practitioners and one anesthesiologist whose case was complicated by preoperative and postoperative care by the family practitioner. Two of the family practitioners were board certified.

Case 1

This case involved a head injury with loss of consciousness.

• The family practitioner, who was the on-call ER physician, left the ER within 15 minutes of the patient’s arrival, without seeing the patient.
• The family practitioner was called twice during the next nine hours by nurses who reported the patient’s complaints of headache, confusion, and combativeness, for which the family practitioner ordered Nubane and Demerol, without seeing the patient.
• Thirteen hours after the patient’s arrival, the family transferred care to an internal medicine physician, and a physical examination was performed.
• When a diagnosis of subarachnoid bleed with intracranial hypertension was made, a decision was also made to place a central venous line.
• The internal medicine physician improperly inserted the central venous line, which probably caused a 20 percent pneumothorax, with the need to place chest tubes.
• The patient was then transferred to a medical center for specialized care.

Problems Identified by the Reviewers

• The family physician left the ER while a patient who presented with head injury and loss of consciousness went untreated.
• The patient was not examined by a physician until 13 hours after arrival.
• The family physician ordered medications without examining the patient.
• Two calls from nurses should have alerted the physician to come to the hospital.
• The patient suffered the additional complication of pneumothorax with chest tube insertion.
• The hours of ER on call for this physician were from Friday to Sunday.
• None of the eight review criteria was met.

Case 2

This patient’s multiple symptoms, related to the GI tract and thyroid, created a need for one ER visit with a follow-up office visit to the family practitioner.

• Diagnostic testing received from the ER included ultrasound of the liver, lab work, chest x-ray, and EKG. All test results were grossly abnormal, and the patient was immediately admitted to the hospital from the office.
• The next day, telephone consultations were arranged for specialty services of cardiology and endocrinology.
• Attempts to transfer the patient to a medical center failed because of severe weather conditions, and the patient continued to deteriorate despite acute care and treatment.
• On the second day, the patient coded three times and died following the third.

Problems Identified by the Reviewers

• The ER physician’s telephone communication with the family practitioner neglected to include the abnormal test results. Therefore, the decision to admit was delayed until the next day when the patient came to the office.
• Of the eight review criteria, six were met and two were nonapplicable.

Case 3

The case review showed a patient with multiple chronic illnesses as well as frequent acute problems over a seven-year period. Most significant was a cardiac history with hypertension for which the patient was treated only by the family practitioner. The sudden demise of the patient demanded an autopsy, which indicated cause of death as myocardial insufficiency resulting from the acute myocardial infarction caused by severe occlusive cardiovascular disease.

Problems Identified by the Reviewers

• Failure to refer the patient for cardiology workup even when the diagnosis included severe cardiac disease.
• Failure to appreciate abnormal test results.
• Failure to recognize chest pain as a significant symptom immediately prior to the sudden death of the patient.
• Poorly documented medical record of the patient’s heart disease and treatment plan.
• None of the eight review criteria was met.

Case 4

This patient’s chief complaint was tingling and numbness in both wrists, leading to a work-related diagnosis of carpal tunnel syndrome. The family practitioner’s diagnosis was well developed, with appropriate preoperative testing and consultation for nerve conduction studies to validate the diagnosis.

The family practitioner performed the surgical procedure of right (most severely affected side) carpal tunnel release. Three weeks postoperatively, the patient was referred to an orthopedist, who confirmed the original diagnosis. Surgical complication of nerve injury appeared within six weeks of the surgery. The patient was referred to another orthopedist three weeks later, and a decision was made to reopen the wound. The wrist exploration revealed nerve damage.

Problems Identified by the Reviewers

• An outside-of-specialty surgical procedure was performed by the family practitioner, whose privileges were for minor surgery only.
• The delay in referring the patient to an orthopedist when nerve injury was first apparent may have created an irreversible situation.
• The medical record was poorly documented.
• An additional medical problem of hypertension lacked adequate workup or follow-up.
• No alternative, noninvasive treatment for carpal tunnel syndrome was attempted prior to surgical intervention.
• Only one of the eight review criteria was met.

Case 5

This adult patient presented to the family practitioner’s office with various symptoms including headaches, tongue-biting during sleep, asthma, incontinence, and wheezing over a nine-month period. The patient was examined on four successive office visits by a nurse practitioner and was also hospitalized with a severe asthma attack.

• Headaches changed in description from “migraine-like” to pounding and persistent over one eye with migration to the neck.
• An EEG taken at the third visit was interpreted as within normal limits.
• Tongue-biting during sleep occurred on two different occasions.
• Asthma treatment was coordinated by a pulmonologist with use of steroidal therapy.
• The nurse practitioner suggested referral to a neurologist for enuresis when steroid therapy was completed.
• The patient, suddenly found in full arrest, was resuscitated en route to the ER.
• ER workup revealed a frontal lobe mass, but the patient was vomiting, which probably caused brain herniation and necessitated a stat craniotomy.

Problems Identified by the Reviewers

• Failure to recognize and appreciate symptoms of intracranial pressure.
• Failure to perform a full and complete workup for patient’s multiple symptoms.
• Failure on part of the nurse practitioner to refer to the family practitioner when the patient returned to the office with the same complaint.
• Failure to refer to a neurologist in a timely manner.
• Failure to order a CT scan or MRI of the head.
• Two of the eight review criteria were not met.

Case 6

This case involved a patient who came to the family practitioner’s office twice with similar complaints of chest pain, shortness of breath, cough, and stuffy nose.

• The physician assistant’s physical examination focused on breath sounds at the first visit.
• The second visit included an EKG that was machine-read as abnormal with left axis deviation, although the physician assistant interpreted the EKG to be within normal limits and prescribed antibiotics and over-the-counter antacids.
• Three days after the second visit, the patient suffered a full arrest, was resuscitated, and subsequently underwent angioplasty.
• A thallium scan postoperatively showed a fixed defect without evidence of reversible ischemia.

Problems Identified by the Reviewers

• Failure to appreciate cardiology-related symptoms.
• Failure to obtain past medical history that included prior myocardial infarction and failure to perform a complete physical examination.
• Failure of the physician assistant to involve the physician at the second visit for the same patient complaint.
• Failure to acknowledge machine-read EKG interpretation.
• Five of the eight review criteria were not met.

Case 7

This patient elected hernia repair surgery and received clearance for surgery from the family practitioner as the patient’s year-and-a-half history of respiratory problems was under control. The herniorrhaphy and postoperative period were without complications.

• The patient’s respiratory problems had been diagnosed by the family practitioner as adult exercise-induced asthma and had been treated with Proventil and prednisone, with an occasional antibiotic for colds and sinusitis. The patient’s symptoms were recurrent.
• The patient also had a medical history of obesity, hypertension, and prior myocardial infarction.
• An EKG taken seven days preoperatively was interpreted as abnormal with evidence of cardiac injury.
• Shortly after the herniorrhaphy, the patient experienced atrial fibrillation requiring emergent cardiac care with surgery. The patient survived the surgery but died a few days later.

Problems Identified by the Reviewers

• The patient’s past medical history was known by the family practitioner but was not communicated to subsequent health care providers.
• The abnormal preoperative EKG result was not shared with either the anesthesiologist or the surgeon.
• The family practitioner made an inappropriate workup of the patient’s respiratory symptoms and failed to recognize their cardiac base.
• Failure to follow up an abnormal EKG.
• Failure to provide appropriate workup and treatment of the patient’s obesity, hypertension, and past cardiac event.
• Seven of the eight review criteria were not met.

What Lessons Can Be Learned from These Seven Case Reviews?

1. Delays in examining patients are difficult to defend. If you are unable to provide timely and appropriate care, arrange for coverage.
2. Physicians have a few key responsibilities related to the ordering of medications and diagnostic tests:
   1. Do not order medications without examining the patient.
   2. Review the patient’s past medical history before ordering medications unless you are very familiar with the patient and the acute problem(s).
   3. If tests are ordered, obtain results within a designated time period, and act on the results. If no action is appropriate, document that as well.
   4. Test results, past medical records, consultations, letters, etc., that will be included in the medical record should be reviewed by a professional health care provider before they are filed.
3. The past medical history with currently relevant medical facts should be communicated to other health care providers involved in the patient’s care. This is a “captain of the ship” responsibility.
4. A primary care physician’s recognition of his or her own limitations will ensure timely and appropriate referrals to specialists.
5. Practicing within one’s own specialty will decrease unfavorable outcomes.
6. Abnormal test results require evaluation with action to be taken even if no action is recommended and may also be necessary when all test results are normal.
7. Positive findings deserve workup and follow-up and so do some pertinent negative findings.
8. If using nonphysician allied health professionals, be sure to develop guidelines for their practices:
   1. If a patient returns with the same complaint, the patient should be seen by the physician.
   2. If computer-interpreted EKGs conflict with the interpretation of the allied health professional, the physician’s opinion should be requested.
9. Overall, the cases presented a significant lack of documentation, which would contribute to a difficult defense.
10. Illegibility of progress notes remains a key factor in our case reviews.

Other Roundtable Guidelines from Panel Members:

Gatekeeper Functions

• Develop protocols for referring patients to specialty care.
• Know your own limitations.
• Determine appropriate follow-up needs, and then act on them.

Read Your Managed Care Contracts to Answer These Questions:

• Is there a reciprocal hold harmless clause?
• Who owns the medical record?
• How can the contract be terminated?
• Is there a capitation agreement?
• What are the denial and appeal processes?
• Should you and how do you keep the patient in the loop during appeals and denials?

Terminating Patient/Physician Relationships

1. Keep in mind the few occasions when termination is not recommended:
   • During an acute phase of treatment
   • If you are the only provider able to treat a particular disease or condition within the geographic area
   • With capitated patients (handled through the MCO)
2. Develop sample letters or templates for consistency of application and to ensure that the following key elements are included:
3. • Effective date of termination (e.g., “two weeks from the date of this letter…”)
   • Emergency care–only provision prior to the effective date of termination
   • Ten to 30 days’ notice for patient to find another provider
   • Referral to sources of physician lists, local medical society, hospitals, etc.
   • Access to a copy of the medical record with the patient’s signed authorization

Supervising Physician-Extender Responsibilities

• Comply with state-regulated supervision processes.
• Define the role that each will play in the practice, remembering that the physician assumes full responsibility.
• Monitor and evaluate performance levels at regular intervals.
• Be readily available.

The Art of Talking to Patients

Panel members are strong advocates of the informed-consent process, as it is one of the most important services that physicians provide to patients. Fundamentally, family practice is about communicating the nature of their health or disease to patients and their options for treatment. Do not hide information from patients regarding the existence or specifics of an appeal process. It is important for patients to understand their options. Physicians should encourage patients to stay involved in their care with a treatment plan that is tailored for each patient. For some patients, this may mean sending copies of correspondence to the insurance company; for others, it may mean verbal communication.

Alternative Health Care Alert

Many patients now consume over-the-counter products that include an array of herbs and other nutritional supplements. To avoid adverse reactions and ensure that your treatment plan not only will be effective, but also will result in a favorable outcome, specific questions should be included in your medical history and physical examination processes.

The question, “What drugs are you currently taking?” will usually be answered, “None,” or will offer the few medications that a physician has prescribed. Make your questions more generic, such as, “Tell me all the medications that you take in a day’s time,” or, “What do you purchase in the drug or grocery store?” Sometimes even greater detail is needed: “Do you take any of the following: aspirin, Anacin, Tylenol, herbs, herbal teas, or weight loss products?” Asking the correct questions at the initial visit can decrease bad outcomes.

Miscellaneous Topics

1. Telephone triage within the office practice must be carefully developed with protocols applied by knowledgeable persons. The safest route is with the use of professionally trained personnel, such as registered nurses, nurse practitioners, or physician assistants. All calls should be reviewed at regular intervals and fully documented in the medical record.
2. Testing performed within the office setting should comply with the standard of care for that particular specialty. For example, the family practitioner with x-ray equipment in his office that might be used for chest x-rays must realize that he will be held to the same standard as the radiologist. It is far better to have an agreement with a radiologist who will perform the interpretation for you.
3. Documentation needs have not changed, and they continue to be a key to defense or avoidance of litigation. A well-documented medical record can prevail in trial even with an unfavorable patient outcome, as the ability to prove compliance with the standard of care is the deciding factor. Do not focus on documenting faster—do it smarter. Look for and use efficient processes.
4. If dictation is your current practice and you find yourself facing 20 to 30 records at day’s end, try a different tactic: Dictate in the patient’s room with the patient present. Why is this effective?
   
5. • Details are fresh in your mind.
   • The patient has an opportunity to hear again what you have just told him or her.
   • The patient has the opportunity to provide corrections: Doctor states right knee is troublesome, but patient says, “No, it’s the left knee.”
   • It takes the physician about three to four minutes to complete his or her dictation, but the patient’s perception is 12 to 15 minutes with you—an impressive statistic.
   • The patient may now have a better understanding of the medical record content.
   • The patient can ask questions if he or she still does not understand the treatment plan, and you have the chance to assess his or her level of comprehension.

Conclusion

Risk management in primary care utilizes those reasonable and commonsense values that should be an integral part of the practice of medicine. A good medical record, a careful informed-consent process, open communication between the physician and patient and between the physician and other health care providers, an assessment of the patient’s level of understanding, and diffusion of anger are some of the key elements. Angry patients sue, but action taken in lieu of reaction afterward may diffuse that anger. Common courtesy and respect can prevent litigation.

The Doctors Company remains committed to our ongoing risk management program as a means of enhancing patient care and preventing lawsuits.

J4223 2/05

Updated: May 2000
Originally published: April 1990

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