This month we look at a very common issue, what happens if a physician orders blood work and a patient fails to have it done and then suffers adverse consequences? It would make sense that going for ordered tests or for blood work is a patient’s responsibility once the physician has prescribed the test or blood work. That isn’t always the case, however. The answer is going to hinge on the particular facts of each case, as we see in this month’s story.

Facts of the Case

The physician in this case, Dr H, was a psychiatrist. He had been treating the 19-year-old patient, Miss P, for bipolar disorder. The psychiatrist had weekly appointments with the patient, and as part of her treatment he prescribed lithium to help reduce the frequency and severity of Miss P’s bipolar depression. During the time that he treated her, Dr H increased her lithium dose. As part of her treatment, Dr H wrote prescriptions for Miss P to have her blood work done to monitor the levels of lithium in her bloodstream. Miss P never had the blood work done.

After a couple of months of treatment, Miss P was hospitalized with signs of lithium toxicity. She had experienced hair loss, stomach problems, and hand tremors. After she recovered, Miss P hired a plaintiff’s attorney and filed a lawsuit against Dr H alleging that the psychiatrist had failed to obtain the necessary blood draws and had missed the signs and symptoms of lithium toxicity during several weeks of psychiatric visits. In addition to the medical damages, Miss P claimed that her ordeal caused her to lose her trust in psychiatry.

Dr H felt he had been wrongfully sued. He knew that he had provided the patient with prescriptions for blood work. When he met with his defense attorney, he said just that, and that if the patient chose to go against medical advice, then the consequences weren’t his fault. The attorney advised Dr H that the plaintiff had indicated that she was willing to settle the case for $250,000, but Dr H refused. The case went to trial.

The Jury Decides

At trial, the plaintiff, Miss P, testified that in the 8 weeks leading up to her hospitalization she had the signs and symptoms of lithium toxicity. She described suffering from hand tremors, inability to concentrate, hair loss, diarrhea, vomiting, and confusion. She claimed that Dr H failed to obtain regular blood draws and thus missed the warning signs that she was developing lithium toxicity. She further claimed that the psychiatrist had failed to notice her symptoms.

Dr H testified that the fault of the plaintiff’s lithium toxicity lay with her, and not with him. He testified that after increasing her lithium dose, he had given her a total of 5 prescriptions to have her blood drawn and that she had failed to follow through on the orders. On the witness stand, the psychiatrist disputed Miss P’s claims that she exhibited signs of lithium toxicity at her weekly psychiatry visits. He ended his testimony by stating that he had complied with the standard of care and had monitored his patient’s clinical state at each visit, but he had not observed any indications of lithium toxicity. Regardless, testified the psychiatrist, Miss P brought the situation on herself by failing to obtain the required blood work.

In response, the plaintiff introduced medical experts who testified that the plaintiff’s bipolar disorder caused memory loss, which the psychiatrist should have been aware of, which prevented Miss P from complying with the doctor’s orders. In addition, the experts pointed out that lithium, in itself, has the potential to cause poor concentration, which the psychiatrist should also have been aware of. And finally, the medical experts questioned why, after weeks had passed with the psychiatrist writing blood draw order after blood draw order that were being unfilled, why he didn’t take some other action, such as draw blood in the office, or help her set up an appointment.

At the end of closing arguments, the plaintiff’s attorney asked the jury to award the plaintiff over $500,000. After deliberating for over 4 hours, the jury returned with a verdict for the plaintiff, and ordered Dr H to pay $125,000.

The ‘low’ monetary award (less than half of what the plaintiff was asking to settle the case), is an indication that either the jury did assign some of the blame to Miss P for not following up on her blood work prescriptions, or that the damages that she suffered were not permanent or severe.

Protecting Yourself

It is worth noting that, as usual, good recordkeeping can help or harm a case. In this case, Dr H’s notes clearly indicated that he had written 5 prescriptions for blood work. When the plaintiff in the case tried to argue that he had not ordered blood work for her, he was able to refute that immediately via the patient’s medical records.

But, as the medical experts pointed out, the patient’s psychiatric condition of bipolar disorder in itself caused memory loss and confusion, and knowing this, the psychiatrist should have done more to ensure that the patient’s lithium levels were tested. What might he have done? As the medical experts pointed out, he could have potentially obtained a blood draw in the office. He also could have followed up with the patient, which it appeared he failed to do. Knowing that the patient potentially had memory issues, he could have had office staff follow-up with the patient. Or he might have asked the office staff to assist the patient with making the appointment for the blood work. He could have sent text reminders. And while obviously a physician can’t force a patient to get a test, in this case it wasn’t the patient’s unwillingness to get the test that was stopping her, it was her inability to remember that it was necessary due to her medical condition. Thus, a reminder, or a system of reminders, could have prevented this.

If you practice in a field where you typically prescribe medication that requires monitoring, in addition to ordering whatever tests are necessary, it is also important to consider the patient’s diagnosis and whether there is anything about the diagnosis (or even the treatment) which might prevent the patient from being able to properly follow up with orders. Take into account whether your patient might have any memory or other impairment which would prevent him or her from understanding the necessity of following up.