Time Pressure Leads to Serious Consequences for Clinician

During his orientation at the clinic, Dr. P was told that clinicians should try to limit patient interactions to 10 minutes as they would be rated by how many patients they treated, and there was a minimum.

The practice of medicine is becoming increasingly challenging. Low insurance reimbursements, a shortage of primary care providers, and high numbers of patients have put a great strain on medical practices, and have caused some to enact internal policies which regulate how many patients a practitioner is supposed to see per hour. Such limitations can have ramifications…as we find in this month’s case.

Medical Lawsuit Facts

Dr. P was a 33-year old general practitioner working for a fairly large walk-in family clinic. He had only been at the clinic for a few months, but was finding it greatly different than his previous employment in the office of an aging family practitioner. His previous employer was what some would call “old school” – he knew all his patients by name, always took the time to speak with them, never rushed, answered their phone calls personally, etc. But the physician had retired and sold his practice to the clinic, which offered Dr. P a position.

The clinic was the polar opposite of his experience with the family practitioner. During his orientation, he was told that clinicians (there were several physicians and nurse practitioners) should try to limit patient interactions to 10 minutes. He immediately began to voice his opinion that this wasn’t necessarily long enough, but the administrator went on to explain that the clinicians would be rated by how many patients they treated, and there was a minimum. Dr. P was not happy with the situation, but nevertheless thought he should give the job a fair try.

A few months into his time at the clinic, a teenage girl was brought in by her father. The girl, Miss C, spoke both English and Chinese, but she reported to Dr. P that neither parent spoke English. The father stayed in the waiting room while Dr. P spoke to and examined his patient.

Miss C reported having a stomach virus over the previous few days and still feeling queasy. During their discussion, she mentioned to Dr. P that her parents were getting divorced and that she’d been having trouble sleeping, was feeling sad, and her schoolwork was suffering. She reported that she’d been feeling this way for several weeks. Dr. P nodded, and made a note, all the while monitoring the wall clock hanging over the patient. The physical exam was normal, with the exception of the patient’s nausea.

“Is there someone at school…a counselor or someone…that you could talk to about your situation at home?” the physician asked.

The girl shrugged, morosely. “I don’t know.”

Dr. P was torn. He wanted to take more time to speak to the patient, but he was already running late due to taking too long with some of his earlier patients. He’d been warned once already about not getting his patients in and out promptly enough, and didn’t relish another warning. So he sighed, and wrote out two prescriptions for the patient, one for an anti-nausea medication and one for fluoxetine for depression.

“Your father speaks no English?” Dr. P asked.

“None,” said Miss. C.

The physician thought for a moment. He knew there was no one in the office that spoke Chinese, so he would be unable to speak to the girl’s parent. “I’m sending you home with two prescriptions – one to help with the queasiness and the other is an anti-depressant to help you feel better, happier. It’s important that you take them as prescribed. I want you to come back here in four weeks for a follow-up. If at any time you feel worse, I want you to call the clinic right away – okay?”

The teen nodded and left, and Dr. P moved on to his next patient.

Three weeks after seeing Dr. P, and a week before her follow-up appointment, Miss C hanged herself with a belt. She was discovered by her mother and brother and rushed to the hospital, but she had suffered catastrophic brain injury and required round the clock care. She died 3 years later and her parents sought the counsel of a plaintiff’s attorney who took on the case against Dr. P.

Dr. P was shocked and saddened to hear about what happened to the girl, and to find that he was being blamed. He met with the defense attorney provided by his insurance company. “I don’t believe I did anything wrong,” he told the attorney. “I prescribed appropriate medication for the patient. I think it was her situation – the divorce – that was the real culprit.”

Legal Background

The case slowly proceeded to trial. Depositions were held. Experts were hired.

At trial, the plaintiff argued that fluoxetine should not have been prescribed because Miss. C was not showing signs of clinical depression. The plaintiff also pointed out via experts that the FDA had issued a black box warning regarding the use of fluoxetine in adolescents – specifically that it increased the risk of suicidal thinking and behavior. In an impassioned closing argument, the plaintiff’s attorney argued that Dr. P should never have prescribed the antidepressant to Miss C without speaking to her parents or explaining the warnings directly to her.

The defense argued that the clinical evaluation for depression supported the diagnosis. The defense also noted that the suicide attempt immediately followed a breakup with the patient’s boyfriend and a fight with her father.

The jury found for the plaintiff, and awarded over $3 million.

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Protecting Yourself

The time pressure felt by Dr. P caused him to overlook communication options with the patient’s father. If he couldn’t find an employee who spoke the language, he could have used the computer to translate the basics for the father, or at the very least had the father come into the exam room and have the patient do the translation. Not properly communicating with a 15 year old’s parent when prescribing an antidepressant was extremely unwise.

As the plaintiff’s attorney pointed out, there is a black box warning for fluoxetine regarding the risk of suicidal behavior in adolescents. Dr. P should clearly have told the patient to be aware of this, and should have made the parent aware of it as well. A different choice of antidepressant might have been made, or better yet, Dr. P should have considered referring the patient to a psychologist or psychiatrist for an assessment. Perhaps the teen could have been helped with talk therapy. The best option is not always prescribing something, although this is often what patients want and expect.

The bottom line in this case is this: take the time you need to adequately assess your patient, or face the consequences.