With today’s hectic schedules and health insurance issues, many people simply don’t bother to make appointments for checkups or well-patient visits. Instead, they only go to their health-care practitioners when they are actually ill. Is it the clinician’s responsibility to remind patients to come in for checkups, vaccinations, and other routine but necessary visits?
Ms. C was a nurse practitioner working for a primary-care physician, Dr. W. The two clinicians each saw patients—often taking turns when one patient came in repeatedly—so that they would both be equally familiar with all of their clients.
As is to be expected, Ms. C was fonder of some patients than others. One she particularly liked was Mrs. S, 35. Ms. C was impressed with Mrs. S’s work ethic and her grace in difficult circumstances: Mrs. S was raising her autistic 10-year-old son alone. Her husband had deserted her when the child was a toddler, and Mrs. S had been struggling to support herself and her son with very little assistance from her family. The patient had moved to the community five years earlier, hoping that a smaller town would be a better place for her and the boy. The child was cared for by a pediatrician in an adjacent building, and Mrs. S would sometimes bring the boy with her when she came in to be treated by Ms. C and Dr. W. Ms. C knew that money and child care were hard to come by for Mrs. S, yet the patient always tried to be cheerful and upbeat.
Mrs. S made sure to have her medical records transferred over to Dr. W’s practice when she moved to town, so the clinicians were aware that although Mrs. S was in otherwise good health, she’d had a splenectomy prior to relocating. Over the last few years, Ms. C had seen Mrs. S five or six times for minor complaints that included a bad case of poison ivy, an ear infection, a sore throat, and a twisted ankle. Dr. W had also seen her an additional two or three times for similar issues.
Late one afternoon near closing time, the office manager told Ms. C that Mrs. S was on the phone. Ms. C took the call.
“I’m really not feeling well,” said Mrs. S. “I’ve had a fever for a few days, my joints ache, my head hurts, and I feel very weak. I was wondering if you might have time to see me tomorrow morning.”
“I won’t be in until the afternoon,” replied Ms. C, “but Dr. W can see you before then. In the meantime, drink plenty of liquids and get some rest—it sounds like the flu.”
The next afternoon, when Ms. C came to work, Dr. W was looking unhappy.
“I sent Mrs. S to the hospital,” he said. “By the time she came in here, she was having difficulty breathing, had spiked a 103˚F temp, and had extreme joint pain. I suspect a pneumococcal infection. I’m very concerned.”
The two clinicians looked at each other grimly, and Ms. C then pulled the patient’s file.
“She had the splenectomy about seven years ago,” said Ms. C. “The records indicate that they gave her a Pneumovax vaccination in the hospital.”
“She’s been coming here for about five years,” said the physician. “Did we ever revaccinate her, or suggest she get revaccinated? Anything in the notes?”
Ms. C skimmed them, but she already knew the answer. “No,” she said. “She was always here for sick visits, never for a checkup.”
Dr. W shook his head. “I didn’t suggest it, either,” he said, “but I should have.”
Mrs. S did indeed have a serious pneumococcal infection, resulting in a three-month hospital stay. While hospitalized, she became septic and suffered organ failure and necrosis. As a result, she had to undergo a partial amputation of her toes. After the three months in the hospital, Mrs. S had to spend an additional two months in a rehabilitation residence. During this time, she had to leave her son in the care of her mother, and was unable to maintain her job.
Ms. C visited the patient in the hospital and found her to be a changed person: Mrs. S was stressed, angry, and bitter. “How am I going to run after my boy without my toes?” she asked Ms. C. “How am I going to take care of him without a job? Why did this happen to me?”
While Mrs. S was recuperating, another physician asked her whether she’d had another Pneumovax booster since the one she had received in the hospital after her splenectomy. When he learned that she hadn’t, he mentioned to her that her primary-care providers should have revaccinated her. Armed with this information, Mrs. S called a plaintiff’s attorney to explore her options. After having an expert review the records, the attorney agreed that the patient’s primary-care practitioners breached the required standard of care by not telling her that she needed another pneumococcal vaccination. A lawsuit was filed against Ms. C and Dr. W.
The clinicians met with their own attorney and explained that the patient never actually came in for a checkup. “We never examined her in the context of a wellness visit or for preventive care—all of Mrs. S’s visits were for acute-care issues,” they informed the attorney.
After several discussions, the parties agreed to mediation. The case settled for $500,000.
Mediation is a form of alternative dispute resolution—a way to resolve disputes between parties without resorting to trial. An impartial third party—the mediator—helps the parties negotiate a settlement that is acceptable to both sides. The difference between regular negotiations between parties (and their lawyers) and mediation is the presence of the third-party mediator and the fact that mediation has more structure and a timetable.
Mediation is often a good alternative to trial, which can be costly both in money and time, and is often more successful than regular negotiations because of the assistance of the mediator. If the mediation fails and no settlement is reached, the parties have not forfeited their legal rights; they can still go to trial. Whatever takes place during the mediation remains private and confidential.
In this case, the clinicians decided that mediation was preferable to a trial and would provide a better outcome for both themselves and their now former patient.
Unfortunately, patients do not always schedule regular exams or preventive visits. And it is often hard or impossible to attend to health-maintenance issues when a patient is in for an acute-care visit. But the fact is that many people unwisely only see their clinician when they are ill. With patients like this, it is advisable to both verbally remind them and make a note in their file that they should return for a regular checkup, and to schedule routine blood tests and immunizations. It is especially important to remind patients who are elderly or have chronic health issues of the importance of immunizations.
In this case, seeing that Ms. C and Dr. W knew that Mrs. S had had a splenectomy, they should have counseled her to get a pneumococcal vaccination since she was a high-risk patient. Had they given her that advice and had she chosen to ignore it, they would have been protected from any liability. Had they given her that advice and had she chosen to follow it, this story could have had a happier ending for all involved.