Medscape Editor's Key Points:
Complex diagnostics should be interpreted by a specialist, even if a physician fears that over-referring could harm the patient.
Being an effective physician often means asking for help with patient care.
If a problem persists, it may be wise to call in a specialist, even when some test results are normal.
When in Doubt, Call in the Experts
Family practitioners know that good specialty backup is essential for the health of their patients. They also believe that because over-referring to specialists can sometimes harm patients, they should do their best to treat within their skills.
The limits of those skills may be reached in the interpretation of complex diagnostics: Sometimes after a bad result, the only error committed by a family practitioner turns out to be trying to do too much without a specialist's assistance.
Dr. FP is a family practitioner with a busy practice that includes urgent care patients. Mr. E, a 45-year-old executive, saw Dr. FP many times over the years for routine medical needs. Despite Dr. FP's suggestion early on that Mr. E schedule a full physical exam, Mr. E chose instead to continue to visit Dr. FP on an urgent care basis for such complaints as sinusitis and upper respiratory infections.
A month after a visit for allergic sinusitis, Mr. E presented with complaints of tightness in his chest and a burning sensation in the anterior chest for about 2 days. Mr. E said the pain came and went, at times felt like indigestion, and diminished with relaxation. He told Dr. FP that he worried that he might have a heart problem.
A chest x-ray was normal and Dr. FP read Mr. E's EKG to be "100 percent normal." Further evaluation revealed that Mr. E had engaged in vigorous gardening and that his anterior chest wall was very tender to compression.
Upon further discussion with the patient, Dr. FP concluded that Mr. E had costochondritis, for which he prescribed Cataflam and Toradol. On a return visit 1 week later, Mr. E told Dr. FP that his symptoms had completely resolved. Lab results for Mr. E, who was mildly overweight, showed cholesterol of 212, triglycerides of 154, HDL of 31, and LDL of 150.
Mr. E's cardiac risk was 6.9, the upper end of normal. Dr. FP counseled Mr. E on diet and exercise and advised him to return in 4-6 months for a repeat panel. Instead, the patient returned the next day, stating that he had chest pain similar to what he experienced a week earlier.
This time, an EKG showed evidence of an acute anterior septal infarct. After a repeat EKG showed the same finding, Dr. FP told Mr. E that he had had a heart attack and that he must get to the emergency room immediately. Because Mr. E told Dr. FP that he would refuse an ambulance transport and Mrs. E could not be reached, Dr. FP arranged for a member of his own family to drive Mr. E to the hospital.
Mr. E required a bypass surgery and claimed a shortened life expectancy in his lawsuit against Dr. FP for failing to properly diagnose his condition prior to the injury.
The case focused on Dr. FP's chart entry of an EKG being "100 percent normal." Though that test, on review, was not abnormal, it, combined with the patient's complaints of pain, suggested that Dr. FP would have benefited the patient by referring him to a cardiologist.
According to statistics on medical malpractice lawsuits, misdiagnosis of cardiac conditions resulting in myocardial infractions is a leading cause of claims against family practitioners. With family doctors on the firing line for cardiac screening, it is increasingly important for them to know when to call in the expert reinforcements.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "Family Practitioners and EKGs."
© 2018 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
Cite this: Gordon T. Ownby. Malpractice Case: When 'Normal' Test Results Get You Into Trouble - Medscape - Dec 19, 2018.