Last Word

November 18, 2005

Academic experts need policing

The role of medical experts in our legal system is to provide accurate peer evaluation. When they do, the system tends to work as it should. But when they testify inaccurately about the standard of care in a given situation, the system is undermined. Let me illustrate what I mean from my own experience.

A 67-year-old patient with a history of hypertension, hypercholesterolemia, and a family history of coronary artery disease came to my office. The patient-let's call her Betty Smith-was complaining of nonexertional, substernal chest pressure, accompanied by jaw pain lasting up to four hours, typically when lying down. The pressure, I determined, wasn't associated with nausea, dyspnea, or diaphoresis. When her ECG indicated non-specific ST-T wave changes, I referred her to a cardiologist, who, in turn, ordered an adenosine sestamibi stress test. The ECG portion of the test demonstrated questionable ischemic changes; the adenosine portion of the test showed equivocal changes. In short, the stress test was inconclusive.

The cardiologist's office informed Mrs. Smith that her test was normal. She didn't return to him, but I saw her at one to three month intervals, primarily to treat her anxiety and depression. At no time during this period did she complain of chest pain or pressure. But six months later, Mrs. Smith died unexpectedly at home. An autopsy revealed multivessel coronary artery disease involving the left anterior descending artery and the circumflex. There was no acute myocardial infarct, however. Nevertheless, Mrs. Smith's family sued both me and the cardiologist I'd referred her to.

The case could have gone otherwise. Perhaps the outcome for Mrs. Smith would have been different had I questioned the cardiologist's interpretation of her stress test. But it's not the standard of care for an FP to do that. Dr. Jones also erred when he faulted me for not ordering a catheterization: An FP simply can't order a surgical procedure.

Dr. Jones was brought in because of his academic credentials, but his testimony presented the standard of care inaccurately. No wonder the plaintiff's attorney said at one point, "Medical experts are like jukeboxes-attorneys pay for the song they want to hear."

The time has come, I believe, for the heads of medical schools and the chairs of academic departments to step in, calling to account the so-called expert testimony of these medical mercenaries. If a physician has distorted the standard of care in a specific case, that physician should be disciplined. For lesser infractions, the faculty member's superiors might call upon him to suspend his work as an expert witness. The most serious cases might result in a faculty member losing his academic title, regardless of his rank or tenure.

If nothing else, the threat that unprofessional testimony could result in sanctions might prompt some medical experts to confer with colleagues before testifying. If they're on shaky ground, they'll think twice about proceeding. If their colleagues endorse their view, their testimony would at least be more defensible if challenged because it would reflect a broader community of opinion.