Case Closed!

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A Friend in Need

by Ann S. Lofsky, MD

Physicians are often asked to provide medical advice to friends, family, and colleagues. This might be a brief “elevator consultation,” a request for a prescription refill, or an office visit combined with socializing or lunch. The more casual nature of these encounters might make it seem that there is less of a duty to uphold the standards of a full doctor-patient relationship, but as the following claim illustrates, that may not be the case.

Our insured family practitioner provided medical care for his good friend and former college roommate, a healthy 45-year-old man who had occasional sports injuries and chronic back pain resulting from old football trauma. Their two families had remained close throughout the years and, in fact, had just returned from a three-week European vacation together. The physician received a phone call from his friend two days after their arrival home, complaining of a “terrible cold” with an unremitting cough that was not improving.

Since the insured was in his office at the time, he told his friend to come in immediately. When the man arrived at the office, it was clear he was having bouts of nonproductive coughing. His temperature was 101°F. The insured heard decreased breath sounds at the left lung base, so he ordered a chest x-ray, which he read as showing a left lower lobe infiltrate. He diagnosed the man with pneumonia.

As his friend did not appear to be severely ill, the family practitioner prescribed oral levofloxacin and suggested several days of bed rest at home. He phoned his friend a number of times over the next few days and was told that things were slowly improving. On day four after the office visit, the patient’s wife phoned the insured, stating that the man’s coughing was getting worse. She described his breathing as labored and stated that he was having difficulty finishing sentences without taking a breath. When asked whether she thought her husband should be hospitalized, she responded that she did not.

The insured spoke with the patient by phone. The man was obviously coughing, but he did not appear to be short of breath, and he affirmed his desire to avoid going to the hospital at that time. The family practitioner told him that if things got any worse, he should have his wife take him to the emergency room. The physician said that he would stop by their house before going to his office the following morning.

Later that night, the patient awoke and collapsed on the floor while on the way to the bathroom. He was unconscious and unarousable. His wife dialed 911 and was instructed to perform CPR while awaiting the paramedics, who arrived five minutes later. They found the man to be apneic with an agonal rhythm. He was transported to the ER in full arrest.

Could the Insured Have Done Anything to Prevent This?

A chest x-ray performed in the emergency room during CPR revealed bibasilar atelectasis, but no infiltrates. The code was run for 35 minutes before the man was pronounced dead. The autopsy findings included multiple pulmonary emboli (PE) bilaterally, with the cause of death being a massive saddle embolism to the right lung—the likely source being a right calf deep venous thrombosis.

The man’s wife told the insured she thought he had “blown it big time” with his treatment in this case. She knew that her husband would not want her to file a lawsuit against his longtime friend, but she felt that his life insurance policy would not be sufficient to support their three minor children without his income. She filed a medical malpractice wrongful death claim against the insured on their behalf.

A defense expert family practitioner stated that the insured met the standard of care. The diagnosis of PE can be difficult and is often made postmortem. With the cough, fever, and infiltrate on x-ray, it was reasonable to diagnose pneumonia and to treat this patient at home with levofloxacin, an appropriate antibiotic choice. The patient declined hospitalization, leaving the insured few options.

The plaintiffs’ expert reviewer, however, felt that the insured failed to adequately appreciate the seriousness of the lower lobe consolidation and unrelenting cough. The reviewer stated that the standard of care would have required performing a more thorough physical exam and ordering at least a complete blood count and sputum cultures. The patient should either have been hospitalized or asked to return in 24 hours for a repeat examination.

While all experts agreed that the presenting signs of PEs are nonspecific, the plaintiffs’ experts opined that the history of the long plane flight, combined with a nonproductive cough and low-grade fever, should have raised suspicion of the diagnosis and caused the insured to examine the patient’s legs or ask specifically about any new leg pains or tenderness. It was suggested that the subsequent prolonged bed rest might actually have exacerbated the situation.

The experts were critical of the fact that the insured never specifically instructed this patient to go to the hospital. The family practitioner admitted he had never really told his friend that he thought he should be hospitalized, so it is not certain the man would actually have refused to follow medical advice.

Should This Case Be Tried?

The family practitioner believed he had done nothing wrong. He felt the man had pneumonia that was appropriately treated, and only later did he develop the pulmonary emboli—which could not have been foreseen. There were a number of issues in this case, however, that made it problematic to defend. There was no radiologist’s report because the insured had read the initial chest x-ray showing the left lung infiltrate himself. Because the patient was a “drop-in” that morning, the man’s chart was not pulled, and the x-ray was never affixed with a patient identification sticker—which would normally have been the routine. During litigation, the x-ray could not be located in the insured’s office. This opened the possibility for the plaintiffs to claim that the man never really had pneumonia at all and that the family practitioner had simply misread the film.

Additionally, the autopsy report included a toxicology screen revealing the presence of morphine, meperidine, and hydrocodone in the patient’s blood. The man’s wife produced multiple bottles of pills and injectable solution vials that had been prescribed by the family practitioner for his friend over the last year. Not all of these prescriptions were listed in the man’s office chart. The insured insisted these had been prescribed to treat his friend’s chronic back pain and that the man had never abused them. The plaintiffs argued that the patient should have been instructed to discontinue these medications when he developed breathing difficulties, as they are all respiratory depressants and might have clouded his judgment about whether he wanted to go to the hospital.

Not all of the phone calls between the insured and the patient’s home were documented in the medical record. Although phone records did confirm that the physician had called the house daily, the wife disputed the insured’s account of what she said regarding how ill the patient appeared to be. Because of these issues and the sympathy that the death of an otherwise healthy man leaving a widow and young children would likely engender in a jury, the family practitioner agreed to settle this case. While the plaintiffs’ initial demand was excessive, The Doctors Company was able to negotiate a reasonable settlement within the insured’s policy limits.

What Can Be Learned from This Case?

Deaths due to pulmonary emboli remain a relatively frequent cause of malpractice claims across many specialties. Physicians should be alert for the symptoms and signs and at least consider the diagnosis when appropriate. A big problem in this case, however, was the fact that the family practitioner was treating this patient differently than he normally would have because the man was a friend. The insured admitted that rarely would he phone a patient daily without requiring a return office visit, but his relationship with this man and his wife gave him a confidence in them that he would not otherwise have had.

Although the family practitioner was usually quite meticulous in his office charting, because his friend often visited the office socially, not everything was documented in the record as it should have been. Frequently, the insured had x-ray readings confirmed by a radiologist, but to save his friend the insurance deductible, this step was omitted.

In this case, medical care likely suffered because of the unusual nature of the physician-patient relationship, yet no second standard of care exists for friends and family. Either the insured should have rigorously adhered to his usual professional routine, or he should have referred this man to another physician. As one expert stated, “If you can’t treat someone like a patient, then don’t treat them
at all.”

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