Ms. H loved Wednesdays. The nurse practition­er enjoyed her work with Dr. R—the general practitioner who had employed her for the past eight years—but she was eager to stretch her wings, and Wednesday was her day to do so. Dr. R was an old-fashioned physician. He was pretty set in his ways, and although a good mentor for Ms. H, he preferred to do everything himself. In recent years, Ms. H felt constrained by this, and she periodically asked for more responsibility. Dr. R was initially reluctant, but he had been slowing down and was hoping to gradually reduce his hours at the practice.

Dr. R decided to start taking Wednesday mornings off, allowing Ms. H to manage the patient load on her own. Ms. H mostly handled well-patient checkups and the usual minor illnesses: influenza, bronchitis, sore throats, and the like. Dr. R kept his cell phone on during his Wednesday morning golf game and urged Ms. H to call with any questions or concerns she might have. But throughout the first six months of the new arrangement, Ms. H never felt the need to call. Everything was going smoothly.

One Wednesday morning, Mr. B, aged 20 years, came in for a checkup. College was starting in a month, and he needed some medical forms filled out for the athletic department at the university he would be attending.

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The young man excitedly told Ms. H about his basketball scholarship. They chatted as she went through his exam, until she asked him to be quiet as she listened to his heart.

“Hmmm,” she said, quietly.

“What?” asked Mr. B.

“I’m hearing a little heart murmur that I hadn’t heard before,” said Ms. H. “It’s probably nothing, but I’m going to give you a referral for an echocardiogram that I’d like you to get before you go to school.”

Ms. H noted in the patient’s chart that there was a slight systolic murmur, wrote out a referral form for the echocardiogram, and handed it to Mr. B along with the address and phone number of where to go for the test.

“Don’t forget my forms,” the young man reminded her.

Ms. H smiled, filled out the college health forms, handed them to Mr. B, and sent him off.

Although she noted the echocardiogram referral in the patient’s record, Ms. H did not flag the folder for follow-up before filing it away. Over the next few weeks, Ms. H attended to numerous patients and forgot to check whether Mr. B’s results had come in.

In fact, the young man never went for the echocardiogram; he decided to put it off until his next school break. Mr. B left for college and began playing competitive basketball. Everything seemed fine for several months, until Mr. B suddenly collapsed in the middle of a game. Emergency medical personnel were called, and despite numerous efforts at resuscitation, Mr. B died. The official cause of death was hypertrophic cardiomyopathy.

The young man’s parents were shocked, distraught, and angry. They knew that their son had been approved to play sports by Ms. H, and yet the coroner told them that hypertrophic cardiomyopathy is a genetic defect and that a heart murmur is often associated with the condition. Mr. B’s parents consulted a plaintiff’s attorney with a copy of their son’s medical records in hand—documents indicating that Ms. H had noted the systolic murmur and ordered an echocardiogram.

“Did your son go for the test?” asked the attorney.

“Apparently not,” answered the parents. “He didn’t even mention it to us. He must have forgotten or thought he could put it off.”

“Do you have a copy of your son’s college medical forms?” asked the attorney.

Mr. B’s parents produced the forms, which had been signed by Ms. H, stating that their son was in excellent health, indicating no physical restrictions on his athletic activities.

“We have a case,” said the attorney.

Shortly thereafter, Ms. H and her employer were sued for malpractice. In speaking with her defense attorney, Ms. H explained that she had referred Mr. B for an echocardiogram and fully expected that he would go.

“I really just made the referral as a precaution,” she said tearfully. “I didn’t imagine it was anything serious.”

The case went to trial. There, the plaintiff’s attorney introduced the signed release forms as evidence. He also presented the young man’s medical records showing that Ms. H had noticed a heart murmur and was concerned enough to order an echocardiogram.

An expert physician testified that a systolic heart murmur is commonly associated with hypertrophic cardiomyopathy and that hypertrophic cardiomyopathy is a well-known cause of sudden death in athletes.

“For this reason,” testified the expert, “students with this condition are generally disqualified from playing college sports.”

Ms. H testified that she heard the slight murmur and immediately referred the patient for an echocardiogram.

“I explained to him that he needed to have it done,” she said. “I gave him the referral and the address and phone number. I assumed he would follow up.”

During closing arguments, the defense argued that Mr. B should have gone for the echocardiogram and that he had contributed to his own death by ignoring the referral. The plaintiff further argued that given her concern about Mr. B’s heart murmur, Ms. H should not have signed off on the release forms indicating that the young man was fit to engage in college sports.

The jury deliberated for several days before coming back with a verdict in favor of the plaintiffs and awarding $1.2 million in damages.

Legal background

As part of the defense, Ms. H’s attorney argued contributory negligence on the part of Mr. B, alleging that he was partly responsible for his own death because he did not get the diagnostic test that was ordered. While contributory negligence is a legitimate defense in many cases and can often be successful, in this case, any argument of contributory negligence was quashed by the fact that Ms. H had signed off on the medical-release forms.

Protecting yourself

The moral of this story is obvious: Do not sign any medical-release forms if you are in any way unsure of the fitness of the patient. Clinicians are asked on a daily basis to sign such documents for schools, employers, and camps. Rubber-stamping these forms when there is a question about the patient’s health places the clinician legally at risk. Always await the results of a diagnostic test, and do not sign off on health-related forms until you have all the facts.