As an experienced physician assistant, Ms. F had numerous responsibilities that included renewing medications for older patients and checking pediatric patients for acute infections. But even such routine tasks as these can present a challenge. One of Ms. F’s most difficult patients was a 53-year-old smoker who came to the clinic one afternoon while Ms. F’s supervising physician was away. The man’s primary complaints were dizziness and earache. Ms. F attributed these symptoms to labyrinthitis, which had recently made the rounds throughout the community.

Since Ms. F did not have much experience treating this condition, she called her supervising physician for advice. After listening to a description of the patient’s symptoms, the physician offered treatment guidelines, which included an anti-inflammatory and antivertigo medication. The patient was discharged with instructions to return to the clinic if necessary. When her supervising physician returned to work, Ms. F gave her a full update on the case.

Nothing more was reported until Ms. F was told that the patient had been admitted to the hospital after becoming weak and disoriented five days after his last visit. At the hospital, he was given low-dose heparin for a stroke in evolution. According to later testimony, the treatment was too late to be effective, and the patient suffered a massive vertebrobasilar stroke that left him paralyzed and bedridden with severe cognitive deficit.

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Confronted with the probability of huge medical and nursing-home bills, the man’s family made an appointment with a malpractice lawyer to discuss their options. The lawyer arranged to have the patient’s chart analyzed by a team of expert clinicians. The resulting report was critical of the treatment the patient received from Ms. F. The experts concluded that if the correct diagnostic tests had been performed (i.e., a CT scan and an MRI with contrast), the man would have been placed on anticoagulants, and the stroke avoided. Three months after learning of the patient’s stroke, Ms. F was notified that a malpractice suit had been filed against her. This did not surprise her, but the extent and severity of the charges were harsh. She was accused of “substandard medical care” leading to “severe and permanent physical injury.” Her feelings about the patient’s poor outcome were compounded by the accusatory language in the legal documents, and she braced herself for a long and painful ordeal.

A battle over the release of medical records and other documents caused the discovery period to drag on for nearly one year. The family testified that the clinic receptionist had been told that the patient had recently been staggering while walking and experienced drooping on the left side of his face. Ms. F’s testimony never mentioned these symptoms. The patient had a history of mental instability, and the defense lawyer sought these records to see what bearing they might have on his current mental status (which was severely impaired after the stroke). The plaintiff’s lawyer opposed the release of the records, fearing that this would divert attention from the missed diagnosis of impending stroke. The defense filed a motion to compel release, the plaintiff’s lawyer refused, and the two sides turned to the judge for a decision.

At the hearing, the judge faced a considerable dilemma. State law held a high standard for the confidentiality of mental-health records. Their release was allowed only if the plaintiff’s lawyer had been the one who put the patient’s mental status in question. The judge had to determine whether the patient’s mental status had been raised when the plaintiff’s expert testified that the stroke had caused cognitive damage. The plaintiff’s lawyer argued that this issue was different from that of mental-health status. Sensing that the plaintiff was trying to conceal something, the defense intensified its efforts to have the records released. While the lawyers jockeyed for position, the judge continued to work through the issues and study the briefs. After a week of contemplation, he announced that he would not allow the defense access to the patient’s records. The judge explained that he considered the mental health of the patient different from the results of a stroke on the brain. The defense immediately began preparing an appeal while simultaneously negotiating a settlement with the plaintiff’s lawyer. Facing extended litigation and the preparation of an appeal brief, the plaintiff agreed to settle for $50,000. The controversy surrounding the patient’s mental health was never resolved. He partially recovered from the stroke and remained in a wheelchair for the rest of his life. Ms. F returned to her work at the clinic.