This month’s case examines what could happen when a clinician diagnoses and prescribes based on complaints being relayed to her, without seeing, or even directly speaking to, the patient.
Dr. V was a family practitioner with a very busy small practice. The 55-year-old physician employed a receptionist to staff the front desk and answer the phones, and a medical assistant to prep patients and take vitals.
One of the physician’s patients was Mrs. C, 69. The patient had been seeing Dr. V for the past four years for hypertension, asthma, osteoporosis, COPD, urinary tract infections, and allergic rhinitis. The patient, who was obese and had trouble getting around, came in with frequent complaints, most recently in early May for a sprained ankle.
On July 7th, as the physician was preparing to step into an exam room, her receptionist flagged her down.
“Mrs. C is on the phone,” said the receptionist. “She says that she’s experiencing a burning sensation upon urinating. Should she come in?”
The doctor glanced at her schedule. There was no time to squeeze Mrs. C in, and the physician knew that it was difficult for the patient to get to the office.
“Tell her that I’ll call in a prescription for Cipro to treat her UTI,” said Dr. V, and she directed the receptionist to note the call, the complaint, and the fact a 7-day course of antibiotics had been prescribed to treat the infection, in the patient’s record.
Two weeks later, on July 22, the receptionist caught the physician as she was between patients.
“Mrs. C called again while you were with a patient,” said the receptionist. “She said she has a bad cough and was coughing up mucus.”
The physician again looked at the schedule, sighed, and told the receptionist to call the patient back and advise her that the doctor would be calling in a prescription for a 10-day course of Ceftin, and Tussionex. The receptionist noted this in the file, and called the patient to advise her.
On July 28th, Mrs. C called the office again, this time complaining that she was not feeling better and that she had developed a slight fever. Again, the patient spoke only to the receptionist, who conveyed the message to the physician. This time the physician prescribed Tessalon Perles and recommended that the patient continue the antibiotics. (This information was again conveyed by the receptionist to the patient, and again the receptionist noted the content of the conversation with the patient, and the physician’s recommendations in the file.)
The following day, July 29th, the patient called the physician’s office again to report gas pain and loose bowel movements. Dr. V, via the receptionist, told the patient to discontinue the Ceftin, and that she would call in a five-day course of Cipro instead. The patient was also advised to take Immodium.
This was the last time that anyone at the physician’s office would speak to Mrs. C. Two days later, the patient presented to the emergency department of her local hospital with symptoms of diarrhea and a low-grade fever. She was found to be hypotensive and dehydrated. Lab studies indicated an elevated white blood cell count and hyponatremia. The patient was admitted to rule out sepsis, colitis, or diverticulitis. An imaging study showed what was believed to be an ileus in the small bowel. Stool cultures revealed antibiotic-induced C. difficile bacteria. The consulting surgeon believed that the patient had pseudomembranous colitis secondary to C. difficile infection. The patient’s condition continued to worsen, and on August 3rd she was taken for exploratory surgery. The surgeon resected a large segment of ischemic distal ileum, but described the colon as normal in appearance. After surgery, the patient’s condition continued to worsen and after life support measures were discontinued, the patient died.
The patient’s distraught husband contacted a plaintiff’s attorney who, after hearing the facts, accepted the case and filed a lawsuit against Dr. V, alleging that she negligently failed to see the patient on July 28th and 29th, and failed to diagnose C. difficile colitis that led to the patient’s death.
When Dr. V was notified about the lawsuit, she contacted the defense attorney provided by her medical malpractice insurance. The attorney was concerned after reading the file and speaking to the physician. He retained several medical experts to look at the patient’s records.
All of the medical experts were critical of Dr. V and felt that she should have seen the patient on July 28th or 29th when she called reporting no improvement in her symptoms and new-onset diarrhea. Failure to see the patient in the office at this point was a below the standard of care, agreed the experts. The case inched towards trial. During depositions, Dr. V testified that antibiotic-induced C. difficile infection was “not on her radar” with respect to the patient’s telephone complaints.
Trial began, but a settlement was soon negotiated and the insurance company made a payment on behalf of Dr. V to settle the case.
Four basic elements are necessary for a medical malpractice case: 1) a duty of care (this exists in a doctor-patient relationship), 2) a breach of this duty, 3) damage (the patient must have suffered emotional or physician injury), and 4) causation (there must be proof that the breach of duty caused the patient’s injury.) While in this case it was clear that Dr. V had breached her duty of care, and all the experts agreed on this, what the experts did NOT agree on was whether this breach had been the cause of the patient’s death. The defense experts believed the cause of death was due to ischemic and infarcted small bowel, and that the C. difficile infection was merely a complication. The plaintiff’s experts, of course, were prepared to argue that the infection caused the patient to become hypotensive and dehydrated, leading to a decrease in blood perfusion. Unless all four elements have been satisfied, a case for medical malpractice is not made. The defense attorney in this case was prepared to argue the element of causation, but realized that settling the case was a far safer bet.
Dr. V made two very large errors in this case. The first was to diagnose and prescribe on the phone, without seeing or examining the patient. This is a dangerous proposition, but physicians occasionally do this when the patient is suffering a common or recurrent problem, or there is no other option. However in this case, when the patient’s issues were not improving, Dr. V should have seen her in person.
Dr. V’s second major error was that she delegated all the communication and note-taking to someone (her receptionist) with no medical background. Dr. V never spoke to the patient directly herself. As a physician, Dr. V might have been able to elicit more information from the patient.
As a general rule, avoid prescribing and diagnosing on the phone. Do not have a receptionist or non-medically trained person handling phone triage. If you cannot see your patient, at the very least speak directly to them.