Ms. U is a 39-year-old physician assistant who worked at the student health clinic of a university in the Northeast. Her supervising physician had weekends off, while Ms. U and a nurse rotated Saturdays at the clinic and took call. This worked fairly well, and patient care was considered good. In fact, the university’s advertising campaign featured its state-of-the-art managed-care facility, but the clinic’s reputation (as well as the reputations of its employees) was put on the line when a malpractice lawsuit claimed that its standard of medical practice was archaic.

The patient was an 18-year-old woman who presented to the clinic complaining of slight fever, lack of energy, and malaise. It was the beginning of flu season, and Ms. U had already seen dozens of patients with similar symptoms. A physical examination revealed a temperature of 100.8°F, pulse 84 beats per minute, respiratory rate eight breaths per minute, and BP 100/65 mm Hg. The patient had a red throat and rales in the chest on both sides. Abdominal and cardiovascular exams were unremarkable. Ms. U took the chart to her supervising physician, who reviewed it and then signed off on the treatment recommended (rest, fluids, analgesics, and review). The student went back to her room, and Ms. U returned to her patients. 

The student’s symptoms persisted, but she did not return to the clinic until four months later. She complained of an inability to void, low-grade fever, dry lips, and weakness. Again, she was diagnosed with the flu or other viral illness and sent away on the same treatment as before. Two weeks later, the patient returned with the identical symptoms. She was so weak that she had to be helped into the office by her roommate and a security guard. After being seen by the nurse, the young woman was sent back to her dorm room with the same diagnosis. In accordance with the clinic’s policy, the chart was reviewed the following Tuesday by the physician who signed off on Ms. U’s original diagnosis and treatment. No blood work had been done during any of the patient’s three visits, despite the ability of the clinic to draw blood and have it sent out for testing.

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When the student’s mother heard about the extent of her daughter’s weakness and the persistence of her symptoms, the older woman immediately made arrangements for her daughter to return home and be seen by a private physician. Before that could happen, however, the student collapsed in her room and was rushed to the local ER. There the staff took note of her white color and severe dehydration and ran some lab studies. Her hemoglobin came back at 0 g/dL, and the slide was choked with the large cells of acute myelogenous leukemia (AML). While the patient was being transfused and rehydrated, she coded suddenly and died. Once her daughter’s funeral arrangements had been made, the mother scheduled an appointment with a plaintiff lawyer and asked him to file a malpractice suit against the student health clinic and the providers who had treated her daughter.

The case proceeded to trial after settlement negotiations broke down. The plaintiff lawyer argued that the student’s life was unnecessarily lost through the clinicians’ negligence, since AML was a treatable disease with a mortality of 50% or less. The plaintiff experts testified that a complete blood count was indicated at each visit, if only to confirm the diagnosis of viral infection. Further, the patient’s complaint that she could not urinate suggested dehydration so severe that her kidneys had shut down (an immediate indication for IV rehydration). The fact that she was so weak she could not stand was an indication to perform blood work and admit her to the hospital.

After a recess, the jury awarded the plaintiff $4 million. The judge noted that the clinic was part of the university, which itself was a charitable institution and therefore eligible for the state’s charitable immunity statute. This placed a limit of $20,000 on the award to each parent. In accordance with the terms of this statute, the judge reduced the award to $40,000.

Charitable immunity

Most states have charitable immunity statutes that place a cap on jury awards in an effort to protect charitable institutions like universities. These protections apply only to activities related to the institution’s charitable functions. The appeal in this case centers on whether the student health clinic (run by an HMO) was part of the educational activities of the university. In a number of states, plaintiff lawyers have successfully excluded motor vehicle accidents and functions peripheral to the main charitable activity.

The plaintiff lawyer made much of the university’s advertising of “high-quality care” available at the student health clinic and contrasted the claim with the reality of the care that the student received. The jury’s strong reaction to this contrast  was reflected in its $4 million award to the woman’s parents.

Risk-management principles

Risk managers view the patient returning with the same complaint as a “second chance”—an opportunity to reduce litigation by careful review of the case and further testing. The actors in this drama twice neglected this opportunity to review their previous work and correct any error or oversight.

The returning patient should command close attention and thorough lab workup appropriate to the situation. However, there are several barriers to implementing this policy, primarily the psychological difficulty of changing a diagnosis made by a respected colleague. Studies show that there is an unconscious reluctance to correct a colleague, even if the diagnosis is clearly wrong. It takes a significant amount of detachment to re-examine the original diagnosis and treatment plan. Perhaps the greatest aid in doing so is the awareness of this psychological foible. A written policy may also be helpful, stating that the senior provider available should re-evaluate any returning patient and that the charts of all returning patients should be reviewed for diagnostic errors.

Another effective risk-management strategy for returning patients is a follow-up call or visit after a second discharge. Study of a disease over time adds a new perspective to the diagnostic process and may make clear what was once obscured at the clinic. If a follow-up call is impossible, a repeat office visit can be just as valuable (though less convenient). If the patient does not show up, this should be clearly noted in the chart and reasonable attempts should be made to contact the person.

The severely ill student-patient may be difficult to detect, since most are generally inexperienced in the language of illness and may find it difficult to verbalize their symptoms. Because they are healthier than other patients, young people can also have serious illnesses with little disability.

Improving technology may make it possible to do simple blood counts on all patients with infections. This will be a tremendous aid in the triage of patients into bacterial infections, viral infections, and more serious conditions.