Physicians and their staff have a hard enough time getting their patients to understand the urgency of undergoing follow-up testing. When the condition looks serious and a frequently traveling patient has a history of noncompliance, getting him or her to a specialist – or to the ER – may be what’s called for.
A 48-year-old gentleman whose business frequently required world travel had high blood pressure, high cholesterol, and a family history of heart disease. Between his initial visit with his internist, Dr. IM, for a sleep disorder and his final visit seven years later, the patient showed a propensity of not adhering to his blood pressure medication regimen. Midway through that period, Dr. IM prescribed a statin for high cholesterol.
During a work project, the patient’s schedule took him to five different cities in Europe and the Middle East. While on a break in Denmark, the patient experienced a sudden onset of chest pain which he described to his wife as a burning sensation. The gentleman went to an emergency room, where he was diagnosed with an eye and lung infection and placed on a 10-day course of antibiotics. Several days later, the patient sent an email to Dr. IM requesting that a physical exam be set up.
When the patient visited Dr. IM some two weeks after the ER visit in Denmark, he said he still had burning in his chest, which he described as “like you inhale fire.” Dr. IM diagnosed essential hypertension, high cholesterol, vitamin D deficiency, and migraine without aura. Spirometry was normal, and Dr. IM charted an EKG that day as normal, though the printout of the scan noted “abnormal ECG.” Dr. IM noted a possible infection and extended the patient’s antibiotics.
Dr. IM also prescribed benazepril (the patient was off his blood pressure medications again) and Lipitor. Dr. IM ordered a coronary calcium scan and told the patient to return in four weeks. The patient did not undergo the test before leaving the country again. Three days later, Dr. IM left a message on the patient’s voice mail explaining that laboratory results were worse than previous tests and that he needed to come to the office when he returns home.
Ten days later, the patient was found dead in his hotel room in Zurich. An autopsy stated the gentleman died of “acute heart failure caused by an acute coronary infarction after fresh wall hemorrhage in a preexistent high-level constriction of the descending branch of the left coronary artery.”
In a telephone call between the patient’s wife and Dr. IM after the death, the wife told Dr. IM that her husband had told her that Dr. IM had cleared her husband’s travels. Dr. IM charted “this would not have been my usual and customary pattern,” especially with a patient with hypertension, family history, and cardiac issues. The wrongful death suit against Dr. IM filed by the patient’s wife and child was resolved informally without going to trial.
Can a physician be certain that a traditionally noncompliant patient will go to a specialist on a referral? No one can know for sure, but when such a referral is absent, it is the internist who will face the liability risk.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.