Dr. G is a busy 48-year-old physician working for a cardiology group in a large midwestern city. Of the various aspects of his job, his favorite is procedural cardiology. He spends every morning in the catheterization lab and sees office patients in the afternoon. There is no question as to where, of these two places, he would rather be, but he “takes the good with the bad” and “slaves diligently in the office” every afternoon. 
    One of Dr. G’s patients was a 78-year-old woman with atrial fibrillation. Dr. G stabilized her heart rate with digoxin and verapamil before starting her on warfarin (Coumadin) 3 mg daily. When an echocardiogram revealed an atrial thrombus, he was called away unexpectedly just before ordering a routine prothrombin time (PT), and the patient left the office without a lab order. The woman called the office two weeks later complaining of easy bruising and nosebleeds that wouldn’t stop. The next day, she returned to the office, and Dr. G ordered a PT and explained that it would tell him if the Coumadin was causing the bruising. The patient was distracted by other activities, however, and did not go to the lab for the PT. She later testified that she “felt much better,” and although she hadn’t had the test, she continued to take her medication. 
    Dr. G left for vacation the next day. His partner was covering for him when the patient called and complained of a large bruise on her forearm. He told her to stop the Coumadin immediately and go to the lab the next day for a PT. Her PT turned out to be markedly prolonged (35 seconds). After receiving the results, Dr. G’s partner advised the woman to go to the ER for a vitamin K injection. The ER clinician took another PT, which measured 30 seconds, and administered  vitamin K in accordance with the cardiologist’s orders.
    Shortly after arriving home, the patient returned to the ER, complaining of severe back pain. The ER clinician examined her, gave her a shot of ketorolac tromethamine (Toradol), and discharged her with a prescription for hydrocodone (Vicodin). The patient woke up the next day and discovered that she could not move her legs. She was taken to the ER for a third time, where a CT scan demonstrated a large hematoma in the epidural space, compressing the spinal cord at the L2 level. Despite decompression, her paraplegia was permanent. A few weeks later, the patient consulted a lawyer. 
    After receiving notification of the lawsuit naming him, his partner, and two ER clinicians as codefendants, Dr. G sent the paperwork to his insurance agent with scarcely a glance. When the first discovery requests came in a few weeks later, he had already forgotten about the lawsuit. Throughout the discovery process, he sat sullenly and complained continuously about what he felt was a waste of his skill and valuable operating time.
    The case went to trial two years later. Despite Dr. G’s previous reluctance, he was a stellar witness. His good looks, professional bearing, and simplified explanations of the proper use of Coumadin and its potential risks impressed the jury, which eventually decided in his favor. The plaintiff expert was a well-spoken cardiologist and equally impressive, however. This was bad news for Dr. G’s codefendants. They were held responsible for damages of $12.2 million as well as an additional $3 million of interest.

Anomalous verdict

The jury believed that although Dr. G had acted negligently by failing to arrange for a PT when prescribing warfarin, his substandard care did not directly cause the patient’s injuries. This decision surprised Dr. G and his lawyer as well as the other defendants, who had to shoulder the megaverdict on their own. This anomalous result can be explained partially by the convincing testimony of the plaintiff-expert cardiologist, who placed the blame squarely on the clinicians who followed up on the patient after Dr. G went on vacation. According to the expert’s testimony, the other clinicians had multiple opportunities to intervene and prevent the eventual disabling bleed in the spinal canal.
    The large verdict in this case included $3 million in prejudgment interest, which is calculated by the judge from the date of filing to the date of payment at a generous interest rate (typically around 9%) set by the legislature and influenced by the plaintiff bar. This allows plaintiff lawyers to benefit from the delays and inefficiencies inherent in the legal system and to motivate the defense to settle cases rather than face punitive rates of interest if it should lose.
    The defense lawyers argued that the patient should share part of the blame for her overdose of Coumadin, since she neglected to have the PT test ordered by Dr. G. In many cases, juries will hold patients partly accountable for their own complications, especially when clinicians’ orders are ignored or delayed. However, juries appear to be passing much of the responsibility for patient compliance on to the clinician, resulting in greater liability.

Risk-management principles

Lawsuits frequently arise from everyday situations that are handled poorly due to a provider’s oversight. Routine medical events like regulation of Coumadin through PTs should be a well-designed process with little possibility of error and subject to constant scrutiny. By continuously studying real and potential problems and improving the system by which patients are ensured PT measurements once they start on Coumadin, tragic complications like this one can be prevented. 
    The noncompliant patient is a growing risk-management liability. Juries are placing an increasing burden on the physician to ensure that the patient keeps office appointments, undergoes the tests recommended, and takes medications as prescribed. Modern risk-management practice requires that the clinician’s office install simple systems to check on patient compliance, such as calls to the patient the day before an appointment or when he or she misses an appointment. Patients with outstanding lab results should have a tickler in the chart that alerts the clinician or office staff to what is expected. In the case of elderly patients, it can be useful to involve the family to ensure that the ordered tests are completed and the medication is taken as ordered.