Malpractice Case: You're at Risk When Your Patient Fails to See the Specialist

Gordon T. Ownby


February 07, 2020

Physicians and their staff have a hard enough time getting their patients to understand the urgency of undergoing follow-up testing. When the condition looks serious and a frequently traveling patient has a history of noncompliance, getting him or her to a specialist—or to the ED—may be what's called for.

A 48-year-old man whose business frequently required world travel had high blood pressure, high cholesterol, and a family history of heart disease. Between his initial visit with his internist, Dr IM, for a sleep disorder and his final visit 7 years later, the patient showed a propensity for not adhering to his blood pressure medication regimen. Midway through that period, Dr IM prescribed a statin for high cholesterol.

During a work project, the patient's schedule took him to five different cities in Europe and the Middle East. While on a break in Denmark, the patient experienced a sudden onset of chest pain, which he described to his wife as a burning sensation. The man went to an emergency department, where he was diagnosed with an eye and lung infection and placed on a 10-day course of antibiotics. Several days later, the patient sent an email to Dr IM requesting that a physical exam be set up.

When the patient visited Dr IM some 2 weeks after the ED visit in Denmark, he said he still had burning in his chest, which he described as "like you inhale fire." Dr IM diagnosed essential hypertension, high cholesterol, vitamin D deficiency, and migraine without aura. Spirometry was normal, and Dr IM charted an ECG that day as normal, though the printout of the scan noted "abnormal ECG." Dr IM noted a possible infection and extended the patient's antibiotics.

Dr IM also prescribed benazepril (the patient was off his blood pressure medications again) and atorvastatin. Dr IM ordered a coronary calcium scan and told the patient to return in 4 weeks. The patient did not undergo the test before leaving the country again. Three days later, Dr IM left a message on the patient's voicemail explaining that laboratory results were worse than previous tests and that he needed to come to the office when he returns home.

Medscape Editor's Key Notes:

  • Patients who travel frequently can present compliance issues for physicians, so detailed follow-up is important.

  • Be sure to document all communication with patients, even emails, voicemails, etc.

  • If physicians make a referral for traditionally noncompliant patients, they should be sure to document their intention.

Ten days later, the patient was found dead in his hotel room in Zurich. An autopsy stated that he died of "acute heart failure caused by an acute coronary infarction after fresh wall hemorrhage in a preexistent high-level constriction of the descending branch of the left coronary artery."

In a telephone call between the patient's wife and Dr IM after the death, the wife told Dr IM that her husband had told her that Dr IM had cleared her husband's travels. Dr IM charted "this would not have been my usual and customary pattern," especially with a patient with hypertension, family history, and cardiac issues.

The wrongful death suit against Dr IM, filed by the patient's wife and child, was resolved informally without going to trial.

Can a physician be certain that a traditionally noncompliant patient will go to a specialist on a referral? No one can know for sure, but when such a referral is absent, it is the internist who will face the liability risk.

This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "Getting the Attention of Your Wandering Patient."


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