Years of elevated liver enzymes failed to raise concern about a teenager’s condition.

Ms. U, 36, completed a master’s program to become a physician assistant four years ago. Although her specialty was pediatrics, she found a position in a general practice in the Pacific Northwest and gave up her specialty to live and practice there. Ironically, it wasn’t an adult patient who involved her in her first malpractice suit but a teenager.

The patient, a 14-year-old boy, presented with abdominal pain after running into a basketball pole during a pickup game. His parents rushed him to an emergency department, where he received comprehensive monitoring for presumed traumatic abdominal injury, including observation overnight, CT of the abdomen, and serial hematocrit and hemoglobin levels, as well as liver function tests (LFTs).

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The only abnormality appeared in the LFTs, which showed moderately elevated enzyme levels. The patient was discharged the next morning, with instructions to see his family physician for follow-up serial LFTs.

His parents brought him to Ms. U’s clinic, where her supervising physician initially saw the boy. The doctor ordered repeat liver-enzyme tests at regular intervals and referred the patient to Ms. U to be followed over the long term.

When the patient was next seen a week later, Ms. U noticed that the liver enzymes were still elevated, although at a lower level than the discharge summary from the hospital had indicated. She consulted her supervising physician, who asked her to “keep following the enzyme levels until they are normal.”

Ms. U entered this instruction in the chart and, for the next three months, followed the liver-enzyme levels closely. At the end of that time, she noticed that the levels had diminished considerably but were still 10% above normal range. When she consulted her supervising physician, he minimized the abnormality, stating that “they’re probably normal.” He asked Ms. U to monitor them “to make sure they don’t kick up unexpectedly.” Ms. U continued to see the patient periodically over the next three years, during which time he become obese, topping out at more than 300 pounds.

At age 18, the patient saw another physician for a routine employment physical. That physician noted his elevated liver enzymes and referred him to a gastroenterologist. Soon the boy was diagnosed with Wilson’s disease, accompanied by its typical liver destruction and cirrhosis. Assessment of the patient’s cirrhosis revealed portal hypertension, an enlarged spleen, and esophageal varices. He was referred to a major university hospital to be evaluated for an eventual liver transplant.

It was not long before the patient’s parents found their way to a plaintiff’s lawyer, who called for the chart and had it reviewed by his expert gastroenterologist. That doctor found both Ms. U and her physician responsible for failing to refer the patient on the basis of his elevated enzymes. The plaintiff’s lawyer filed a malpractice suit against Ms. U and her supervising physician and had the papers served at the office in front of a waiting room full of patients.

The case progressed through paper discovery to depositions, in which the physician argued that he assumed the patient’s initial liver enzyme levels were caused by the trauma at the basketball game. The subsequent long-term elevations were due to a fatty liver from the patient’s obesity, he said.

The defense expert backed up that assertion by testifying that it was a reasonable assumption to make in the case of a 300-pound teenager. In any case, the defense expert said, the liver damage caused by Wilson’s disease was not curable. Early diagnosis would not have altered the need for eventual liver transplant nor the development of liver complications, such as esophageal varices.

The plaintiff’s experts attacked this viewpoint, saying that any continuous elevation in liver enzymes deserved a gastroenterology referral, no matter what the presumed cause.

After the depositions, the defense team offered to settle for $500,000. The insurance adjuster explained it this way: “Here’s an unmarried 300-pound man in his early 20s, no job or loss of wages, with a virtually incurable condition that would have required liver transplant anyway. It’s hard to place a greater value on the case than $500,000.”

The defense lawyer agreed and approached the plaintiff’s lawyer with that amount, eliciting chuckles of scorn and a counteroffer of $2 million. After some negotiations back and forth, the parties settled for $750,000.

Legal background

Recent legislative changes, labeled “tort reform,” have reduced the awards allowed for pain and suffering, making “hard damages,” such as medical bills and lost wages, more valuable to plaintiff’s attorneys than ever before. In this case, the patient was unemployed, and thus the plaintiff’s attorney was forced to consider future medical bills, such as a proposed liver transplant, as the basis for his damage claim. This limitation on his case reduced the amount of expected damages through a jury verdict, and consequently the settlement value of the case, to a manageable $750,000.

Lessons learned

Consultation is a valuable risk-management strategy in a number of ways:

• It can confirm an important diagnosis.
• It can guard against the rare or uncommon diagnosis that can masquerade as some common problem.
• It can guard against the common and significant problem of diagnostic perseverance. Psychological studies have shown that a wrong diagnosis, once made and accepted by the provider, is difficult to discard even in the face of increasing evidence that the diagnosis is wrong.

However, consultation as a medical- and risk-management strategy should be used carefully and in a graded manner:

• Consult first with a colleague in the office.
• Seek out a specialist to confirm a diagnosis and eliminate rare diseases masquerading as common conditions.
• Have the specialist consultant take over treatment.

Choosing the appropriate level of consultation can make a huge difference in its effectiveness.