The fact is that the majority of medical malpractice cases are disposed of before ever reaching a courtroom. Many are simply dismissed. Of those left, only a handful ever go to a full trial. Why? A legal trial is incredibly costly, stressful, and time consuming with an unsure outcome. When a jury is involved, sentiments such as sympathy for the patient can creep in and bias a trial. For a healthcare practitioner, a lawsuit can be the source of great anxiety and can interfere with work. In a case, such as this one, where the outcome is unclear and the defense is not terribly strong, it is often a better option to work out a settlement instead and avoid the stress and uncertainty of trial.
The medical expert physician in this case correctly pointed out that Dr. P had failed to consider any differential diagnosis when his patient came in complaining of heartburn. Part of this was obviously due to the fact that the patient came in with his own explanation for his discomfort – “my heartburn has gotten worse this week” – and the physician went with that rather than looking for clues on his own. Acute myocardial infarction is often missed in an office setting, and has become a leading cause of primary care malpractice litigation, indicating the significant role primary care practitioners play in early detection and management.1 In this case, Dr. P’s patient was overweight, smoked, was a male in his 50’s, and had elevated cholesterol and borderline hypertension. Because he had previously been diagnosed with GERD, the assumption was that any chest pain was related to that diagnosis. However, the other characteristics of this patient should have led the physician to consider other issues than just worsening heartburn. An ECG would have been another simple diagnostic tool that the physician could have used to determine whether heartburn was really the root of the problem. Instead, the doctor relied on his patient’s assumption instead of digging deeper.
If you are a primary care clinician, it is essential to always consider differential diagnoses when assessing a patient. Particularly in the case of a patient who is reporting chest pain, it is vital to look beyond the surface. As in the case of Dr. P, just because something looks like the obvious answer doesn’t always mean that it is.
1. Thomas D. Sequist, MD, MPH; Richard Marshall, MD; Steve Lampert, MD; Elizabeth J. Buechler, MD; Thomas H. Lee, MD, MSc. Missed Opportunities in the Primary Care Management of Early Acute Ischemic Heart Disease. AMA. 2006.