Mr. A, a 27-year-old physician assistant, was part of a thriving rural practice. Its 30-year history in the same location made for an intimate feel. Small-town life suited Mr. A, as he grew up in this area. When the opportunity came for him to join Dr. O’s practice, he jumped at the chance.

One of his regular patients, Mr. K, aged 43 years, showed up at the office one afternoon. Mr. K was a former factory worker who came in periodically for minor illnesses. Over the past 10 years, Mr. K had experienced a variety of misfortunes: he’d been laid off from his job due to the economy, and the stress of being unemployed had taken its toll on his marriage. He and his wife had separated, leaving their twin teenage boys somewhere in the middle. Although he didn’t have any major health problems, Mr. K had been treated for depression several years earlier. He had a history of unreliability and often did not show up for his follow-up appointments.

“What brings you in today?” asked Mr. A.

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“I hear voices in my head,” replied Mr. K

Mr. A felt alarmed. In his limited experience, he had not dealt with many psychological issues.

“What sort of voices are you hearing?” asked the clinician.

“There are three voices,” responded the patient. “Two are good, but one is evil.”

Mr. A noted this in Mr. K’s chart and started a physical exam. The patient’s heart rate, BP and chest sounds were all normal, and he reported no unusual headaches and rebuffed any suggestion that he might be using recreational drugs.

After 30 minutes, Mr. A still didn’t know what to make of the voices that Mr. K was hearing. He called in Dr. O for a consult.

Dr. O had known Mr. K for years. The two settled into a comfortable talk, as Mr. A looked on.

“So, about these voices,” said the physician, “do they frighten or concern you?”

“Well, I was a little taken aback when I started hearing them,” replied Mr. K, “but seeing as I know who they are, I’m not as bothered anymore.”

“Who are they?” asked Dr. O.

“One is my aunt Iris, gone 20 years now, and one is her sister, Violet. The third voice is my grandfather. He can be rough sometimes.”

“Are these voices telling you to do anything or to hurt yourself?” asked the doctor,

“No, they just like to talk all the time.”

“How is the family?” Dr. O inquired.

“The boys are playing sports, and my wife and I are thinking about giving the marriage another shot,” Mr. K said.

“You still may have some stress in your life,” the physician said. “Here is the name of another doctor who specializes in mental health. Go see him as soon as possible. If the voices start disturbing you, or you feel like you want to hurt yourself, go to the emergency department immediately. Come back and see me next week.”

Dr. O left the room, and Mr. A noted his instructions in the patient’s file and walked him out. That was the last time either practitioner saw Mr. K.

Mr. K did not return for his follow-up appointment. When Mr. A asked Dr. O whether this was a problem, the physician told him that this was typical of Mr. K. He often didn’t come back for follow-ups, but he’d be back the next time something was bothering him.

Mr. K never went to the psychiatrist. Instead, a month after seeing Mr. A, he borrowed a shotgun and fatally shot himself.

The clinicians were shocked when they heard the news, but even more stunned when they were served with papers informing them that Mr. K’s widow was suing them for malpractice. Their attorney advised them to fight the case.

At trial, the plaintiff introduced testimony by an expert psychiatrist, who testified that Mr. K was suffering a psychiatric emergency when he came to see Dr. O and should have been referred immediately to a psychiatric hospital. The plaintiff also introduced a family practitioner as a witness, who testified that a family-practice doctor should not have been treating a psychiatric patient. The physician opined that Mr. K was exhibiting clear signs of psychosis and should have been sent to a hospital at once.

When it was the defense’s turn, Dr. O testified that he had a long-term relationship with Mr. K and that he had never exhibited any suicidal ideation. He testified that he and Mr. A spent an hour with the patient and neither felt that he was a danger to himself.

The jury deliberated for one day before exonerating Mr. A and Dr. O.

Legal background

“Standard of care” refers to the level at which the average, prudent provider in a given community would practice — in other words, how a similarly qualified practitioner would manage his or her patient’s care under comparable circumstances. The malpractice plaintiff must establish the appropriate standard of care and demonstrate that it had been breached. This is most often done with the testimony of expert witnesses who practice in the same field as the defendant.

Protecting yourself

The jury was swayed by the long-term relationship between the patient and the practitioners and the fact that their treatment was based on that history. Had this been a new patient or one with whom the clinicians did not have this background, things might have ended differently.

Although this case was tragic, the clinicians followed several proper steps: They made copious notes in the patient’s file, warned him repeatedly to go to the hospital if he felt that he wanted to hurt himself, and spent considerable time speaking to him in an effort to ascertain his mental state. Even if they had told Mr. K to go to the hospital immediately, there was no guarantee that he would have followed through. n

Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.