How many patients does a busy clinician see every day? Every week? Chances are the number is high. The days of being able to spend large blocks of time with each patient are long gone.
The current economic climate has squeezed everyone, particularly health-care providers who now need to see more patients in less time. This means that clinicians no longer enjoy the same type of personal relationships with patients that were commonplace in the past. In fact, there may be times when a clinician does not even remember treating a patient.
Mr. D, aged 32 years, worked as a physician assistant for a practice with four doctors and three PAs. It was not unusual for Mr. D to see 25 to 30 patients a day, sometimes even more. And while some stood out in his memory because they came in more often or they had an unusual story, there were many whose names and details slipped his mind over time.
In fact, when a former patient, Mrs. Z, sued him for malpractice, he had no idea who she was. After looking over the lawsuit, Mr. D rushed to speak to Dr. A, the physician with whom he worked most closely. Dr. A was also named in the lawsuit. Both clinicians were alleged to have failed to diagnose Mrs. Z’s perforated appendix nearly one year ago. Mr. D had no recollection of the patient or the incident, but Dr. A remembered treating Mrs. Z.
Mrs. Z, aged 68 years, had originally come in for a checkup almost two months prior to developing the ruptured appendix, records indicated. Dr. A had noted in the chart that the patient had a history of gastroesophageal reflux disease (GERD), allergies and arthritis, which were being treated with meloxicam (Mobic), cetirizine (Zyrtec) and esomeprazole (Nexium).
The notes indicated that Dr. A examined the patient’s heart, lungs and abdomen, which were all normal. Mrs. Z was diagnosed with hypertension. Dr. A ordered a urinalysis and blood tests, which showed nothing abnormal except slightly elevated cholesterol. Mrs. Z was instructed to return in two weeks to recheck her BP. At the second visit, her BP was still elevated and a decision was made to monitor it. She was told to return in another two weeks.
At the third visit, Dr. A added amlodipine (Norvasc) to Mrs. Z’s medications to address the still elevated BP. There was no notation on the chart that Mrs. Z had ever complained about pain on any of her three visits.
Mrs. Z returned to the clinic the following week. On that date, she complained about intolerance to amlodipine, and Dr. A switched her to enalapril (Renitec, Vasotec) and instructed the patient to return in another two weeks. Mrs. Z showed up unexpectedly three days later and was seen by Mr. D. According to the patient record, Mr. D ordered additional blood tests, which were normal aside from a slightly elevated cholesterol and RBC, and recommended a change in diet and exercise to address Mrs. Z’s hypertension.
“Do you remember any of this?” asked Dr. A.
“No,” confessed Mr. D. “I don’t remember the patient at all.”
The clinicians’ defense attorney explained that more information would surface at the examination before trial, where they would have an opportunity to question the plaintiff.
Mrs. Z testified that on her final visit to the clinic, she was suffering from serious pain radiating down her right leg. She stated that even after she complained about this, Mr. D never examined her and only recommended ibuprofen for the pain. Four days later, she went to the emergency department (ED) and was diagnosed with a perforated appendix and underwent an open appendectomy.
The ED records indicated a pelvic abscess, extensive adhesions and inflammation in the pericecal area.
Mr. D explained that he didn’t specifically remember the incident, but based on his usual practice, he likely conducted a focused examination of Mrs. Z and palpated her abdomen. If something had been abnormal or if the patient had complained of pain, he would have noted it in the file.
Before trial, the defense attorney filed a motion for summary judgment, asking the court to dismiss the cases against Dr. A and Mr. D. After examining the facts in the record, the case against Dr. A was dismissed. The court did not dismiss the case against Mr. D. Before going to trial, Mr. D settled with the plaintiff for $250,000.
Summary judgment is a determination made by a judge without a full trial. One party in a case will apply for summary judgment to save the time and expense of a trial when the outcome is obvious. A judge only grants summary judgment if there are no material issues of fact in question — in other words, if there is nothing for a jury to decide, both sides agree about the facts, and it’s simply a matter of law. In such cases, and if one party is clearly the winner after applying the law to the undisputed, a judge may grant summary judgment. Otherwise, the decision is left to a jury.
The judge granted summary judgment to Dr. A because there were no material issues of fact. Dr. A’s version of what happened was the same as Mrs. Z’s version, and the judge could clearly determine that there was no legal basis for a malpractice claim. However, the same could not be said for Mr. D, since he and Mrs. Z had differing versions of what had transpired during treatment.
Many of the cases covered in this column have the same lesson, but it is one worth repeating: document everything. If you are seeing 10, 20 or 30 patients a day, you will not be able to remember them all. And if a patient sues, months or even years down the road, it is doubtful you will remember every detail of treatment.
Mr. D should have noted in the chart what actions he performed at the appointment (e.g., complete physical, palpated abdomen) and recorded the outcomes (e.g., elevated BP, normal abdomen). Taking a few minutes to write complete notes could have spared him a lot of anxiety and money in the long run.