Malpractice Consult

April 10, 2000

When the patient doesn't fit the mold

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When the patient doesn't fit the mold

By Edward E. Bartlett, PhD

Diagnostic mistakes or delays account for about 18 percent of lawsuits against doctors, according to the Physician Insurers Association of America. The average indemnity payment on such claims is $177,558. One of the key causes of these errors is failure to properly diagnose patients with a clinical presentation that doesn't fit any textbook definition.

For example, a 52-year-old man presented to the emergency department having endured three hours of sharp, nonradiating chest pain accompanied by nausea and vomiting. The pain began shortly after he ate lunch, and it wasn't associated with breathing or exertion. He reported that burping and vomiting relieved the pain. His BP was 168/94, pulse 78, and he didn't appear to be in acute distress.

The ECG was interpreted as normal, and an antacid appeared to provide some relief. The patient was discharged with a diagnosis of gastroesophageal reflux. Four hours later, he was found dead at home. An autopsy attributed his death to arteriosclerotic heart disease. The ER physicians were sued for malpractice, and they settled with the man's estate.

This patient didn't neatly fit the classic presentation of acute myocardial infarction. Coronary artery disease has many atypical presentations. When a patient complains of chest pain, you're obligated to rule out heart disease, regardless of his age or known risk factors. And remember, it's not uncommon for a patient with unstable angina to have a normal ECG.

As a risk management consultant, I've worked closely with malpractice insurers in developing clinical guidelines. Here are some strategies we've developed for dealing with less-than-clear presentations:

Go back to the history. Too many physicians rely too heavily on testing and technology. When the diagnosis remains elusive, and the patient is not improving, start over and review the history.

Look for patterns.A patient presents with anemia, fever, and weight loss. Taken in isolation, these symptoms are nonspecific and require considerable effort to evaluate. But considered together, they point to bacterial endocarditis, a commonly missed diagnosis. Always place the chief complaint in the context of the patient's prior symptoms and risk factors.

Remember the "drop dead" diagnosis.ER doctors are trained to consider first the diagnosis that could kill. What is the doomsday scenario? When they formulate their differential diagnosis, many doctors consider only the most common conditions. Although that seems logical, it will eventually cause them to miss the infrequent, but lethal, condition. Always ponder the "can't afford to miss" condition whenever the diagnosis remains elusive.

Request a consultation.Medical students are admonished to "stand on your own two feet because you are responsible for the patient's outcome." This promotes independence and confidence. But this attitude can be taken too far. Don't hold on to a patient too long when the input of a specialist could solve the mystery.

Repeat diagnostic tests.An elderly woman had difficulty with swallowing. She'd previously undergone an upper-GI series, which had been interpreted as negative. Her physician requested that she bring in her films. They revealed an abrupt cut in the esophagus. A repeat GI series revealed a large carcinoma constricting the esophagus.

Laboratories and imaging facilities make mistakes more often than we like to admit. Equipment may be improperly calibrated. An X-ray processor may not be operating properly. The specimen could have been switched with that from another patient.

Talk with a family member.A patient may forget or intentionally conceal information that is crucial to reaching the diagnosis. This is especially true with the elderly. With the patient's permission, invite family members into the exam room, and let them round out the history.

Explain the situation to the patient.Don't keep him in the dark. If you aren't able to figure out the diagnosis, tell the patient that the cause of his condition is elusive, and lay out the diagnostic strategy you plan to pursue.

Try empirical treatment.For example, if the patient has constipation, a stool softener may help pinpoint the cause of the affliction. The effectiveness of an antibiotic in relieving urethral itching can establish the diagnosis of urinary tract infection. But beware: Empirical treatment should never be used for an extended period of time as a substitute for a definitive diagnosis. A frequent source of lawsuits is the patient with lower-GI symptoms who's treated symptomatically for months or years and eventually turns out to have colon cancer.

Trust your instincts.Consider this case related by an internist: "A salesman in his 40s walked into my office one morning. He didn't have an appointment. He complained of discomfort in his chest area, which he signaled by waving his palm across his upper chest. His ECG was completely normal. But he was a smoker, and he just didn't look well. I indicated he needed to go to the ER, despite the normal ECG. He initially refused, but I insisted.

"At the ER, he was found to be in the midst of an acute coronary event. You know what tipped me off? He didn't point at his chest with an index finger, which might suggest a localized musculoskeletal problem. He used an open palm, indicated the whole chest area. My stubbornness probably saved his life."

The author is a risk management consultant based in Rockville, MD. Along with Michael I. Rehmer, he wrote The Diagnostic Dilemma: Exploring Risk Management Solutions (Harrisburg, PA: RiskCare, 1999). This department answers common professional-liability questions. It isn't intended to provide specific legal advice. If you have a question, please submit it to Malpractice Consult, Medical Economics magazine, 5 Paragon Drive, Montvale, NJ 07645-1742. You may also fax your question to 201-722-2688 or send it via e-mail tomemalp@medec.com.

 

 

Mark Crane. Malpractice Consult. Medical Economics 2000;7:238.