As a recent graduate of a prestigious nurse practitioner program, Ms. D is well-versed in modern diagnostic medicine and experienced enough to spot an atypical presentation. Nevertheless, one patient’s interrelated problems were exceptionally difficult to sort out, and Ms. D struggled to make a diagnosis.

The patient was a 39-year-old woman who was well-known among the local medical community. She had a variety of symptoms that always seemed to demand immediate, urgent care. Over the years, the symptoms rotated through abdominal, pelvic, and chest pain before progressing to headaches and difficulty breathing. At first, every little symptom tremor was taken seriously, but as  investigation after investigation came up empty, skepticism developed. The patient’s symptoms became accepted as a type of somatization or hypochondriasis that coincided with personal psychological crises. One day, Ms. D’s supervising physician asked her to see the patient while he was busy with another case.

The woman complained of difficulty breathing, back and chest pain, congestion, and a sore throat. Consistent with previous visits, the symptoms came on suddenly and were related to a fight the patient had with her boyfriend. Ms. D also made note of the patient’s lengthy smoking habit, family history of coronary artery disease (CAD), and history of emotional instability. Ms. D related the case to her supervising physician and suggested an ECG. After going over the file, the physician decided against an ECG. He believed the symptoms were more typical of bronchitis than of CAD.

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The next day, the patient was driven to the emergency department with chest pain on coughing, sore throat, and low-grade fever. She was thought to have a chest infection and was discharged back to the care of her physician. The patient returned to the clinic the next week and was seen by Ms. D. She persuaded her supervising physician to order an ECG, which showed an old inferior infarct. Her suspicions aroused, Ms. D arranged a visit to a cardiologist, who found a strongly positive stress test and an estimated ejection fraction of 15% on echocardiogram. The cardiologist referred the patient back to her family physician and recommended she check into a nearby cardiology clinic.

At the cardiology clinic, the woman was told that her heart had been severely damaged by successive heart attacks and she was being assessed for a heart transplant. Three months later, she died unexpectedly after her boyfriend woke to find her “gurgling” in bed beside him. He called an ambulance, but she was declared dead 30 minutes later. The boyfriend consulted a plaintiff’s lawyer and filed a malpractice suit against Ms. D and her supervising physician for failing to diagnose and treat severe heart disease. Ms. D’s supervising physician assured her that the woman’s atypical presentation was difficult to assess correctly and reminded her that she had been the one to make the referral that eventually led to a diagnosis.

During the depositions, the defense lawyer reconstructed each clinic visit from the chart entries and notes to show that Ms. D had done a competent job. The plaintiff testified on behalf of the eight children who had been left without a mother. Finally, the plaintiff’s expert cardiologist testified that while symptoms are often atypical in women, there had been enough indication of heart problems in this patient to have alerted her providers to order an ECG. This would have revealed the problem, enabled early referral, and possibly saved the woman’s life.

The defense experts testified that while some symptoms indicated pulmonary disease or infection, others were suggestive of heart disease. The picture was “confusing.” Ms. D’s supervising physician confirmed this, stating that when the patient’s heart damage had occurred was uncertain. Furthermore, her symptoms may have been due to heart failure rather than coronary events, such as infarct or angina.

All this testimony was repeated six months later at trial. The experts appeared via videotape, while Ms. D and her supervising physician sweated it out in person. The stoic jurors gave no indication as to which way they were leaning. After one day of deliberation, they returned with a decision in favor of the plaintiff. The $3-million award consisted mainly of pain and suffering compensation (the patient had been unemployed at the time of her death). The boyfriend was awarded $1 million and entrusted with managing the rest of the money until the children turned 18.

Legal background

In the early days of malpractice litigation, clinicians were held to a local standard. Plaintiffs’ lawyers were forced to find an area clinician to testify against the targeted provider. They worked hard to change this, inveighing against a “conspiracy of silence” that led local clinicians to avoid testifying against colleagues they had to work with every day. After several years of lobbying, the plaintiffs’ bar achieved victory: State court decisions would now hold clinicians to a national standard of practice. This meant out-of-state medical experts could now fly into town, testify against someone they had never met, and leave without ever making personal contact with the target of their criticism. However, malpractice litigation remains a very local affair. Certain states and communities favor the plaintiff’s side, while other areas remain more conservative. In response to fear that plaintiff-friendly policies will lead to higher insurance premiums and force providers to leave the area, many states have placed limitations on jury awards for pain and suffering and revised their laws to make it more difficult to sue for malpractice.

Risk-management principles

The outcome of this case was not the result of poor risk management. Ms. D had taken a careful history, performed a thorough physical exam, assessed the facts correctly, and consulted her supervising physician about the management plan. The only thing she could have done differently was to more effectively argue that the patient’s clinical findings justified the expense of an ECG. How to go about this varies with the relationship between the provider and his or her supervising physician. Such relationships must be built over a period of time. Ideally, a level of trust in the clinical competence of the provider is reached, and recommendations are accepted rather easily. In other cases, there are barriers to effective communication, and the supervising physician refuses to listen or, as in this case, listens but does not understand the nuances of the case.

Cases of atypical chest pain in women demand special risk-management attention. A high index of suspicion in a female smoker with a family history, combined with appropriate testing and consultation, can uncover surprising positives. Such thoroughness takes time and money. Sometimes the patient does not have the insurance or the financial resources to sufficiently follow through. If this occurs, it should be noted in the chart to avoid later recriminations.

Dr. Starr is a retired physician and lawyer in the Austin, Tex., area. His legal practice included defending clinicians in malpractice litigation.