Physical Medicine and Rehabilitation

Michelle Swift, JD, RN, Patient Safety Risk Manager II.

Physical medicine and rehabilitation physicians, also known as physiatrists, manage medical conditions resulting from disease or injury that alter a patient’s function and performance. Emphasis is placed on a comprehensive patient-centered treatment plan that optimizes function through the combined use of medications, procedures, physical modalities, physical training with therapeutic exercise, activity modification, adaptive equipment and assistive devices, orthotics, prosthetics, and experiential training approaches.

The Doctors Company analyzed 120 claims against physiatrists that closed between 2007 and 2015. The study revealed that the most common patient allegations were improper performance of treatment or procedure (22 percent), improper management of treatment (17 percent), and diagnosis-related claims (failure, delay, wrong) (14 percent). Consider the following case examples and discussions regarding the most common patient allegations.

Improper Performance of Treatment or Procedure
A patient who was referred to a physiatrist for a trigger point injection signed a generic consent form before receiving the injection. Afterward, while still in the office, the patient complained of difficulty breathing and chest discomfort. The physician, believing that the symptoms were secondary to muscle spasms, treated the patient with a Lidoderm patch and offered to call 911 for emergency assistance.

The patient refused the physician’s offer, choosing instead to drive himself to the nearest hospital emergency department. Upon admission, a chest x-ray indicated a right-sided pneumothorax that necessitated the placement of a chest tube. Subsequently, the patient’s pneumothorax completely resolved, but he sued, alleging improper performance of the trigger point injection, lack of informed consent, and failure to diagnose the pneumothorax. The defense expert testified that a pneumothorax is a well-known risk of the procedure. The expert felt it should have been addressed in the consent form, and the discussion between the physician and patient should have been documented.

Informed Consent
Although informed consent cannot completely eliminate malpractice claims, it provides the patient with realistic expectations regarding a procedure, treatment, test, medication, or even the overall treatment plan. An exchange of information between the patient and physician allows the patient to make a reasonable decision regarding his or her own care while preventing surprise, disappointment, and anger. Procedure-specific forms detailing the risks involved should be completed when the discussion takes place. The form should be signed by the patient and placed in the medical record. For more information, refer to our article, “Informed Consent: Substance and Signature.”

Patient Factors
Patient factors can affect the outcome of care and contribute to patient injury. The most common factors include nonadherence or refusing to follow the recommended treatment plan and/or failure to follow up with appointments for tests, labs, or consultations. If you are unable to change the patient’s willingness to accept and follow the plan, document your discussions and education thoroughly and use a refusal to consent form. A suggested sample can be found under Miscellaneous on our Informed Consent Resources page.

Improper Management of Treatment
An elderly female sustained an injury while undergoing physical therapy. The subsequent lawsuit alleged that the physical therapist assistant pushed too hard causing the patient to sustain a fractured rib and substantial bruising.

Physical medicine and rehabilitation often involves a multidisciplinary team that may include a physiatrist, physical therapist, occupational therapist, orthopedist, and a psychologist. It is not uncommon for a patient to name an entire team in a lawsuit, alleging failure to properly manage treatment.

Communication and collaboration are essential components in providing patient care using an individualized care plan. Ensure that everyone on the team is updated about any new information that becomes known during the course of treatment.

Diagnosis-Related Claims
A patient with chronic neck pain and a history of intravenous drug use of heroin was referred for an epidural steroid injection in hope of decreasing the need for opioid prescription medication. A blood culture was ordered due to the patient’s report of having fever and chills for the last several days. The physician determined that, since the patient was currently afebrile, he would proceed with the injection rather than wait for the test results. The blood culture was later returned positive for Staphylococcus aureus bacteremia. During the next several days, the patient complained of weakening legs and malaise. The symptoms were dismissed as possible drug-seeking behavior. Admission to the emergency department two days later and a subsequent MRI indicated cervical spondylosis with myelopathy, a partial cord injury, and discitis.

Differential Diagnosis
Patient assessment issues include failing to establish a differential diagnosis and failing to address abnormal findings. As this case study exemplifies, disregarding clinical information can lead to patient injury.

Furthermore, a physician presented with a patient who prefers not to follow the treatment plan or is making bad choices might disallow or even ignore the patient’s complaints. Obtaining a specialty consultation or transferring the patient to another physician would be appropriate in this situation.

Analyzing closed physical medicine and rehabilitation claims can provide insights into what motivates allegations of injury. By understanding the contributing factors, physicians can improve the informed consent process, identify particular patient factors that impinge upon care, and understand how failures in the assessment process can lead to diagnostic failures.

The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider considering the circumstances of the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.

J10697 09/16


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