At age 56, Dr. V still believes that a good general practitioner should be able to treat a wide variety of conditions. Because there were few specialists in his rural suburban community, Dr. V treated patients who would likely have been sent elsewhere in larger cities. For example, he delivered babies until his malpractice insurance company refused to renew the obstetrics clause of his policy. Obstetrics patients then had to travel 50 miles if they wanted to give birth with a physician present. To a seasoned professional like Dr. V, this was unnecessary, since he considered himself sufficiently qualified and experienced. But, as he would soon learn, medicine changes, and it is difficult to stay current in all areas.

One of the physician’s patients was a 28-year-old woman who had immigrated from the Bahamas three years earlier. She came to Dr. V complaining of vaginal itching and discharge suggestive of an infection. Her social history revealed multiple sex partners before and after her arrival in the United States, and Dr. V tested her for HIV and other sexually transmitted diseases. He felt she was in a high-risk group, so he bypassed the standard enzyme-linked immunosorbent assay screening test in favor of a Western blot test, which came back positive for HIV infection. She was the first HIV-infected patient Dr. V had ever managed, and he eagerly anticipated the challenge of treating her.

Dr. V met with the patient to explain the results of her tests and the need for treatment. She did not seem upset by the news and explained that several of her friends in the Bahamas had suffered the same fate. He promised to do his best to obtain affordable medicine for her, and she was grateful. After consulting various resources on the treatment of HIV, Dr. V started the patient on zidovudine (AZT) and continued the drug for four years, while following her progress with CD4+ lymphocyte counts at regular intervals. He was delighted to find that her count remained >500/mL, and he assumed she was responding to his therapy. Eventually, a large urban hospital took over her care when she moved out of the area four years postdiagnosis. After reviewing her case, the staff determined that she was not infected with HIV after all and stopped the AZT regimen. A second HIV test produced negative results.

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Within a few weeks, Dr. V was notified of a malpractice lawsuit filed against him for his allegedly mistaken diagnosis and treatment. His biggest surprise was the claim that the patient was never HIV-positive. Dr. V called his insurance company with the news that he was being charged with inflicting emotional and psychological damage as well as negative stigmatization upon the patient.

The case plodded through the written discovery phase before arriving at Dr. V’s deposition. The plaintiff experts cited tests and treatments that he had never heard of, criticized his treatment, and held him to an absurdly high standard of practice. The obvious insinuation was that only big-city specialists are qualified to treat HIV-infected patients. As the deposition continued through the afternoon and into early evening, Dr. V convincingly defended his approach in the case and to medicine in general. He felt justified in relying on the results of an HIV test that had only one false positive for every 250,000 tests administered. He also argued that the patient’s Bahamian origin and multiple sex partners made it statistically more likely that she had been exposed to HIV.

The defense team met several weeks after the depositions to discuss settlement options. There had been several offers from the plaintiff lawyer, but the defense was not inclined to settle for a number of reasons. First, although he would have to interpret them frequently for a jury, Dr .V’s notes and his testimony were in good order. Second, his impressive performance at deposition predicted a good trial appearance. Third, the case would be heard by a local jury whose members would likely value his presence in the community. Finally, Dr. V felt he had acted properly and wanted to fight the charges on moral grounds. The defense made no counteroffer, and the case went to trial. In the end, a jury comprising a mixture of retirees and rural citizens found in Dr. V’s favor.

Legal theory

Each case is ideally decided by an impartial jury that applies uniform criteria to the facts and, aided by the detached testimony of experts, sets the standards of medical practice. Jury selection is a crucial part of the process for plaintiff lawyers in search of a megaverdict, and juries vary from case to case. Overall, they cannot be said to represent the diversity of a community since they are drawn from a select, available few. The relative sympathy value of the patient versus the physician is also an important factor, as this case demonstrates. Even in an atmosphere of rising public distrust, the initial presumption is still in favor of the physician. But a harsh, uncompassionate, or otherwise negative impression during the physician’s testimony can quickly nullify this in favor of the plaintiff. Persuasive expert testimony can affect the momentum of a case, but opposing experts are usually evenly balanced in their testimony. This can leave the jury in a quandary and dependent on instinct for guidance.

Risk-management principles

Although there were some indications that the usually reliable Western blot test had produced a false positive in this patient, Dr. V took a reasonable approach to the situation and backed it up with appropriate, but not extensive, chart entries. He was the personification of the competent, caring, and compassionate physician every juror expects to see on the witness stand. Despite their doubts and increasing distrust of authority figures, jurors still want to believe that their health care is in good hands. In most localities, they will grant clinician-defendants the benefit of the doubt.

Dr. V’s independence and confidence in his innocence is commendable, but it can also be dangerous. Considering that he had never treated HIV before, perhaps he would have been better off referring the patient to a specialty clinic for initial diagnosis and workup. Such an approach would have let him treat the patient locally with supplemental periodic review by the specialist. This model is followed by many competent and independent family clinicians across the country.