Medscape Editor's Key Notes:
Physicians need to know about a patient's other caregivers, especially what prescriptions they are writing.
If patients don't provide records from other caregivers, the physician needs to be more aggressive with the request or get on the phone to request the records before continuing treatment.
When patients don't adhere to a physician's drug regimen, the doctor has the responsibility to halt further treatment or get to the root cause of the issue.
Medication Management Requires Full Cooperation
Physicians are hardwired to help their patients. But in doing so, there may come a time when "tough love" is required.
A 53-year-old telecommunications analyst began seeing Dr. I, an internist, and gave a history of allergies, skin concerns, and pterygium surgery 22 years earlier. Because of the patient's complaints to Dr. I regarding his eyes, Dr. I referred him to an ophthalmologist.
The ophthalmologist diagnosed recurrent pterygium in the right eye and performed pterygium surgery 2 months later. The ophthalmologist prescribed difluprednate eye drops post-surgery and issued a refill on a return visit 7 weeks after surgery. That prescription included instructions for tapering after 1 week and discontinuing the anti-inflammatory steroid 2 weeks thereafter.
On a visit to Dr. I 2 months post-surgery, the patient complained of chronic ear pain and requested a referral to an ENT.
Four months after his eye surgery, the patient visited Dr. I complaining of pressure in his eyes and pain from the surgery. The patient told Dr. I that he could not get in to see his ophthalmologist because of insurance issues. He told Dr. I that the difluprednate worked very well for the pain while nonsteroidal anti-inflammatory medications did not.
He asked Dr. I for a refill of difluprednate to use until he could see his ophthalmologist again. Dr. I did an eye examination and assessed bilateral ocular pain and conjunctivitis. Dr. I charted that he explained the risks and benefits of ophthalmic corticosteroids. Dr. I issued a 1-week prescription for difluprednate and requested that the patient obtain his ophthalmologist's records for him.
Seven weeks later, the patient returned to Dr. I complaining of a right earache and seeking a difluprednate refill. The patient reported that he was unhappy with his ophthalmologist and was seeking a new one whom he would visit once his insurance changed. On examination, Dr. I noted a slight increase of vascularity of conjunctiva in both eyes but no growths, lesions, ptosis, or discharge.
He prescribed cefdinir for the earache, a methylprednisolone pack, and difluprednate. Dr. I noted: "Pt. requesting refill of difluprednate eye drops for pain – lost previous bottle. [Pt] says this is the only thing that has ever helped his eye inflammation. Promises he will get to ophthalmology ASAP for IOP monitoring and will only use the medication for 1 week maximum." Dr. I noted that the patient was still aware and accepted the risks of long-term use of the difluprednate.
Early the next year, the patient saw Dr. I for throat and right ear pain and reported that he had been seen by an ophthalmologist and that he was still working on getting records sent. Dr. I charted a normal eye exam, noted a likely viral upper respiratory infection, and advised the man to follow up with an ENT for his ear pain and to continue the workup of his eye discomfort with the ophthalmologist. The patient requested another methylprednisolone pack, which Dr. I prescribed after discussing the risks and benefits.
Several months later (at approximately 11 months post-surgery), the patient again visited Dr. I, who diagnosed otitis media in the right ear and pterygium of the eye. Dr. I gave the patient cefdinir and advised him to follow up with an ENT ASAP. He also told the patient to follow up with an ophthalmologist ASAP for eye discomfort and to return to him in 1 week for a recheck. Dr. I prescribed another methylprednisolone pack after discussing risks and benefits.
On the patient's return visit a week later, Dr. I gave the patient a prescription of difluprednate with two refills.
Nine weeks later, the patient was examined by his original ophthalmologist, who diagnosed steroid-induced glaucoma in the right eye.
On a return visit to Dr. I 3 weeks hence for a possible rotator cuff injury and an ear recheck, the patient reported to Dr. I that a new ophthalmologist told him that he may have optic nerve damage to his right eye or glaucoma. Dr. I's plan was to get the records from the patient's former and current ophthalmologists. In noting "no more oral or ophthalmic corticosteroids," Dr. I referred the patient to physical therapy for the shoulder and to an ENT for chronic ear pain. He directed the patient to return to the office in 2 weeks for a recheck.
Later that year, Dr. I cleared the patient for cataract surgery. He still did not have records from the patient's ophthalmologists.
In a subsequent lawsuit against Dr. I, the man alleged that Dr. I improperly prescribed difluprednate, causing optic nerve damage and glaucoma and necessitating additional future treatment. The lawsuit resolved informally.
Internists may find themselves drawn into the medical care being conducted by specialists. Coordination with those specialists is important, and in the case of a medication with which the internist may not be fully familiar, insistence that the patient get refills only from the original prescribing physician may be the best way to help the patient overall.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "When To Be A Nice Doctor—And When To Stop."
© 2019 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: Care Coordination Requires Action, Not Just Words - Medscape - Sep 24, 2019.