Internal Medicine: Claims/Risk-Reduction Workshop

During a recent claims review panel, The Doctors Company reviewed 19 internal medicine claims. Claims panels such as this one allow expeditious review of many particularly complicated cases, facilitate early identification of emerging trends, and identify areas suitable for risk management.

Numerous themes became apparent from the recent panel review:

• Medically complex cases are increasingly the subject of malpractice litigation.
  
  
• Allegations of premature hospital discharge have become more common. This is a difficult area for physicians because of demands by insurance companies and utilization reviews.
  
  As managed care becomes an inevitable fact of life, physicians must be wary of third-party decisions with consequences that increase liability exposure.
  
  
• Claims involving geriatric patients are becoming more frequent.
  
  
• Suits alleging failure to prevent disease progression are increasingly common. To prevent suits of this type, the doctor-patient contract should be explicit. Patients and physicians should have appropriate expectations of each other. Diligent management of common diseases, such as diabetes and hypertension, is more important than ever.
  
  
• The differential diagnosis of chest pain is a life-and-death matter that must be handled appropriately and conservatively.
  
  
• Good physician-to-physician communication is essential as medicine becomes more complex.

Complex Cases

In one case, the patient was also a physician. He sued his personal pulmonologist for failing to make a diagnosis of veno-occlusive disease of the lung. The consulting specialist, who ultimately made the diagnosis, indicated that this was the earliest diagnosis he had ever seen for a case of this type, which was complicated by several factors:

• The physician-patient never made formal appointments; he just "dropped in" on his consultant. Records were minimal.
  
  
• The suit alleged permanent disability, which was probably associated with the patient’s coronary artery disease rather than with his pulmonary status.
  
  
• There is no treatment for veno-occlusive disease other than transplantation. All the panelists agreed that such a therapy would have been too premature to even consider. Nonetheless, the suit alleged failure to arrange for early transplantation.

A second claim of a complex nature involved a 24-year-old woman who died of hepatic failure within 3 weeks of her initial symptoms. Her death was caused by macrovesicular fatty infiltrate of the liver that was of unknown etiology. This condition is sometimes associated with idiosyncratic drug reactions or exposure to industrial solvents or other toxins, but could not be specifically related to the patient’s history. Though hepatic transplantation was considered, it was believed to be impossible for this patient. The suit was being pursued as a personal mission by the patient’s mother, who alleged that death was avoidable and that the transplantation should have been performed.

Complex Cases Involving Common Issues

Although preoperative screening for bleeding diatheses is a routine part of surgery, this suit alleged that the screening process was inadequate. The patient was a 33-year-old man who presented with a decreased libido, gynecomastia, and galactorrhea. A pituitary adenoma was promptly diagnosed, but the patient failed to respond to conservative treatment. A neurosurgical consultation and second opinion were obtained. The patient’s history included multiple prior surgeries with no bleeding, and the family history was specifically recorded as unremarkable — with two sisters noted to be in good health. Preoperative Protime and P.T.T. were normal. Nonetheless, the patient suffered a disastrous postoperative intraventricular hemorrhage and was found to have von Willebrand’s disease. The disease was present in the patient’s sister as well. The suit alleged that failure to make a timely diagnosis of this condition led to the serious complication that ensued.

This was a difficult case. The coagulation screen used was not fully adequate to exclude a diagnosis of von Willebrand’s disease. On the other hand, the patient gave absolutely no history of significant bleeding despite multiple prior surgical procedures, and he did not inform his physicians of any familial bleeding tendency.

The second case in this group involved a 19-year-old motorcyclist who suffered multiple injuries and was treated in a university trauma center. The patient had a closed head injury with cerebral edema and multiple fractures. He underwent an exploratory laparotomy with splenectomy and was ventilator-dependent. The patient developed a febrile diathesis, and multiple cultures were drawn. Antibiotics were not started because the attending physicians wished to avoid inappropriate (unnecessary) use, and the fever was believed to be caused by pulmonary embolization and brain injury. Though broad-spectrum antibiotics were started 2 days prior to the patient’s death, the allegation was that untreated septicemia contributed to the patient’s demise.

Another case also alleged failure to recognize sepsis in a medically complicated patient. A 62-year-old patient with coronary artery disease was found to have chronic lymphocytic leukemia and underwent a splenectomy for thrombocytopenia. Ascites was present, and staphylococcus aureus was found in the fluid. The differential count on the ascites fluid revealed 75 percent granulocytes. These findings were thought to be spurious, however, and 5 weeks later the patient was readmitted to the hospital with more obvious clinical findings of peritonitis. Nonetheless, 3 more days passed before the diagnosis was made and the patient was treated appropriately. The patient expired 24 hours later. In retrospect, the patient was found to have spontaneous bacterial peritonitis occurring in a setting of cirrhosis. Two opportunities to make this diagnosis were missed.

Previous internal medicine panels have occasionally seen aseptic necrosis of the femoral heads attributed to prednisone therapy. The case described above was unusual because the course of treatment was brief, and multiple joints were allegedly involved with this process. Defense of the case may have been complicated, however, by the absence of a clear-cut indication for the initial prescription of prednisone.

Problems on the Day of Discharge

Three cases alleged inadequate attention given to findings that initially manifested on the day of discharge. The first involved a patient with subacute bacterial endocarditis. Arrangements for home antibiotics were made following 1 week of hospitalization. On the morning of discharge, the patient complained of double vision and light-headedness. He was examined at that time but was discharged nonetheless. He rapidly became worse, developing ophthalmoplegia and hemiparesis. His daughter drove him directly from one hospital to the emergency room of a second facility, where the patient was hospitalized for the next 11 weeks for complications caused by a ruptured mycotic aneurysm.

In a second case, a patient was admitted with diabetes mellitus, dehydration, and right upper quadrant pain. During hospitalization, she was found to have mild, chronic superficial gastritis and an abnormal but stable electrocardiogram (EKG). Interstitial pulmonary edema was noted on her chest x-ray. She improved considerably, was examined by her physician, and discharge was ordered. Two hours later, the patient’s husband asked the physician to reexamine his wife because she complained of shortness of breath. By the time the examination was accomplished, the patient appeared well, and discharge was completed. The patient died later that night. The specific cause of death is unknown.

A third discharge case alleged "rude and premature" discharge. The case involved a contentious patient with long-standing chronic obstructive pulmonary disease who was hospitalized for treatment of severe dyspnea while traveling. The patient wished to control his own medical regime, and personality conflicts with the treating physicians were relatively well-documented in the records. Following discharge, and apparently without specific complications, the patient filed suit with the rather unusual allegation mentioned above.

Complications in Geriatric Patients

A 75-year-old woman was hospitalized for treatment of severe post-herpetic neuralgia. Her treatment initially required narcotics. An order for "laxative of choice" was written on the day of admission. The patient had no bowel movements for 12 days and developed a fecal impaction so severe that she had to be operatively treated. Ultimately, a diverting colostomy was required. A suit was filed naming both the attending physician and the hospital. This case represented an unusual complication of a common problem that was primarily related to poor communication between the doctor and the nursing staff.

A second case, however, raised serious issues regarding standards of care. An 81-year-old patient was hospitalized by her physician of 12 years for an infected left foot. She had a history of atrial fibrillation, transient ischemic episodes, and organic brain syndrome. A staphylococcal abscess was documented, incised, and drained by a surgeon and treated with antibiotics. Following a 12-day hospitalization, the patient was admitted to a nursing home. Within 24 hours, the nurses were unable to obtain a pedal pulse. During the next 4 days, the physician did not respond to notification by the nurses of this problem. Ultimately, a nursing supervisor called the surgeon who had performed the previous procedure. The patient was re-hospitalized, and an above-the-knee amputation was required.

There is an inference in this case that the physician felt further intervention was not appropriate, given the patient’s advanced age and debilitated state. That defense is unlikely to be successful, however, in the absence of any documentation of appropriate discussion with the patient or her family, as well as the failure to respond to repeated calls from the nurses in attendance.

Failure to Prevent Disease Progression

The panel reviewed three cases involving failure to prevent a second neurological episode in patients with a prior history. The first such case involved a 55-year-old woman with a history of pulmonary embolus 9 years previously. She was maintained on Premarin and Provera for menopausal symptoms post-hysterectomy. Three years previously, she had experienced a transient ischemic attack. One year later, she had a new, right parietal infarct that produced permanent left hemiparesis. The allegation was that the patient had been inappropriately continued on Premarin despite her known history of cerebral vascular disease and her continued use of cigarettes. Probably incidental to the case, but notable, is the absence of an indication for Provera in a woman post-hysterectomy.

The second patient in this group was a 64-year-old rancher with a history of alcoholism, hypertension, and trauma. The patient experienced a fall at home and subsequently complained of aphasia and numbness on the left side of his face and arm. A CAT scan was obtained and read (inaccurately) as normal. No neurologic diagnosis was rendered. Four months later, the patient suffered a second stroke that produced a permanent left hemiparesis and disequilibrium. Evaluation at that time showed an 80 percent stenosis of the right carotid artery, and an endarterectomy was performed. The patient alleged that the stenosis should have been discovered following the first episode and that appropriate treatment might have prevented the second stroke.

The third case in this category involved a 58-year-old woman with a history of diverticulitis and a positive family history of diabetes. She had been followed for 4 years by her attending physician. The patient developed yeast vaginitis and complained of moderate neuropathy. A random blood glucose was 350, and cholesterol was 327. Those values were not reported to the patient, and no specific treatment was advised. Two years later she suffered a cerebral infarction that resulted in a right-sided paralysis. She alleged that more aggressive treatment of her diabetes and hyperlipidemia might have prevented her stroke.

Chest Pain

Two chest pain cases reviewed by the panel had unusual features. Both resulted in death. The first involved a 33-year-old massively obese man with hypertension, a smoking history, and several episodes of transient chest pain. An EKG was not performed initially, but hypertensive medication was prescribed. The patient was not seen until 4 years later when he reported having experienced three episodes of chest pain and dyspnea in the preceding months. A tremor was noted, and the patient was found to be hyperthyroid with a T4 of 20. Grave’s Disease was diagnosed, and radioiodine therapy was scheduled. Ten days later, the patient died of a cardiac arrest at home. The beta-blocker that had been started 4 years earlier for treatment of the hypertension had been inappropriately withdrawn and changed to Vasotec. No specific evaluation of the chest pain and dyspnea had been undertaken pending treatment of Grave’s Disease.

In a second case, a 68-year-old man was seen by his primary physician for chest pain. The patient was hospitalized, and initial EKG changes suggested a myocardial infarction. That appeared to be subendocardial, but streptokinase was prescribed. Recent Hemoccult-positive stools were ignored. Four days later, a stress test was suboptimal. The patient was discharged home and referred to a gastroenterologist for further evaluation. He was readmitted the next day with chest and abdominal pain. A stress test was suboptimal, and a gastroenterology consultation was requested. The patient was discharged home on the fourth hospital day and died at home that evening. Autopsy showed a dissecting thoracic aortic aneurysm.

An evaluation of this case showed that no chest x-ray had been ordered at the time of initial hospitalization. During the second hospitalization, a chest x-ray was performed that showed indistinctness of the descending aortic shadow that was consistent with, though not diagnostic of, aneurysm. That condition carries with it a high mortality rate, especially in the setting of an infarction. The case would be difficult to defend because of the failure to obtain a chest x-ray on the initial hospitalization or to evaluate the abnormality seen on the film.

Communication Errors

Inadequate communication is seen in many malpractice suits. In one case, the internist who had provided preoperative clearance for a surgical patient was asked to reevaluate postoperatively when fever developed. An appropriate fever workup was ordered. The surgeon, however, insisted that only he be permitted to inspect the wound, and he failed to detect the infection that developed. That resulted in a complicated case of osteomyelitis and the need to replace a prosthesis that had been installed. Although the panel felt primary responsibility for this problem rested with the surgeon, the internist would nonetheless need to defend herself in the suit.

Absence of Histologic Verification

The physician performed five separate excisions of a "fibro lipoma" over a 2.5-year period. No specimen was sent to the pathologist. Four months after the last operation, a widely metastatic malignant melanoma was found. Though the initial lesion was a large one, the absence of adequate records and the failure to submit a specimen for pathologic analysis made the case virtually indefensible.

J3208 1/99