Malpractice Case: The Danger of Not Referring to a Specialist

Gordon T. Ownby


January 18, 2019

Medscape Editor's Key Points:

  • Taking on the added responsibility of specialized medicine can also add risk and potential liability for primary care physicians.

  • Remember: You are the specialist for your tests, so be sure to know their use and limitations thoroughly.

  • Be sure to refer to a specialist when the facts of the case and the treatment plan warrant.

If You Order the Test, Be Sure You Can Interpret It Correctly

It is not news that primary care physicians are increasingly asked to handle more of their patients' care. Thus, these caregivers often find themselves responsible for more specialized medicine than ever before. This added responsibility can also result in added risk and potential liability.

The law requires that a primary care physician be knowledgeable in the specialty that he or she ventures into. So when a primary care physician orders and interprets specialized tests, he or she will be expected to be thoroughly familiar with their use and limitations.

In late April, a 52-year-old obese gentleman visited Dr. P1, a primary care physician with a medical group, complaining of a flare-up of seasonal allergies and increasing sinus pressure. Dr. P1 prescribed a decongestant as well as an antibiotic for presumed sinusitis.

The patient returned to the medical group on June 15 and told another primary care physician, Dr. P2, of his trouble breathing and clearing his throat, shortness of breath on exertion, and intermittent chest pain below the sternum. He told Dr. P2 that his breathing problems started a little more than a week after taking the antibiotics prescribed by Dr. P1. The patient also reported that he had begun to smoke cigars about two months earlier.

On exam, Dr. P2 found a trace of edema. The heart was regular and lungs clear. Oxygen saturation was at 92 percent and blood pressure was 152/86. Weight was 325 pounds.

Dr. P2 gave the patient a dose of Combivent, which provided some immediate relief. Dr. P2 performed an EKG in the office that showed signs of left atrial enlargement, as well as T-wave inversion at V-1 and T-wave flattening at V-2. A chest x-ray that day demonstrated a mildly enlarged heart with left ventricular apical prominence. A spirogram revealed 82 to 85 percent of predicted values. Dr. P2 ordered a cardiac panel and B-type natriuretic peptide (BNP) test. Though the BNP was normal, all of the cardiac panel values (CK-MB, myoglobin, CPK, and troponin) were elevated. Dr. P2's plan was to have the patient undergo an echocardiogram and return in a month. The cardiologist who read the patient's echocardiogram done that day attributed an enlarged atrium [and] ventricle to the patient's very large body size.

The patient returned to the medical group on June 22 because of continued difficulty breathing on exertion. As Dr. P2 was on vacation, the patient was seen by Dr. P1, who noted that the patient's lungs were clear, the heartbeat regular, and extremities free of edema. A cardiac biomarker panel ordered by Dr. P1 showed normal values except for a slightly elevated CPK. After discussing the patient informally with a cardiologist, Dr. P1 placed the patient on a beta-blocker and instructed him to take aspirin four times daily and to not overly exert himself.

Per Dr. P1's recommendation, the patient underwent a Persantine stress test and a Myoview on June 30. The cardiologist interpreting the stress test found no ischemic ST changes, chest discomfort, or arrhythmias. The radiologist found the Myoview normal and estimated the patient's left ventricular ejection fraction at 63 percent. An EKG performed that day showed T-wave inversion at V1 to V4.

On July 14, the patient returned to the medical group, where Dr. P2 had returned from vacation. He complained to Dr. P2 of shortness of breath and tightness in his chest, with improvement when he used the Combivent inhaler. He had stopped taking the antibiotic. With the patient's heart regular and lungs clear, Dr. P2 prescribed a different inhaler, Advair, and instructed the patient to return in a month.

The next week, the patient's daughter found him collapsed and unresponsive in the bathroom of his home. He was pronounced dead at the hospital. No autopsy was performed. The cause of death was deemed "probable arteriosclerotic coronary artery disease." The patient's family sued Dr. P1, Dr. P2, and various healthcare entities for wrongful death.

The family contended that Dr. P2 was negligent in not referring the patient to a cardiologist or to the emergency room for a cardiac workup when he complained of shortness of breath and chest pain on June 15.

They specifically complained that Dr. P2 failed to appreciate the significance of the complaints, coupled with the EKG findings, elevated cardiac enzymes, normal spirometry, and risk factors. The family further contended that Dr. P2 negligently failed to make a cardiac referral when the patient returned in mid-July with shortness of breath and chest "heaviness," particularly in view of the two EKG studies taken on June 15 and June 30. The family also said that Dr. P2 failed to prescribe the correct medications and that what he did prescribe was contraindicated.

The litigation was resolved informally.

Jurors are accustomed to being seen by specialists for their acute medical needs, and a primary care physician risks their swift judgment for any shortcoming in specialty areas. When evaluating specialty cases and treatment, primary care doctors need to take the initiative by referring to a specialist when the facts warrant.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "You Are the Specialist for Your Tests."


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