Discontinuity of Care: Two Physicians, One Practice and One Patient's Tragedy

“Continuity of care.”  We often think about this concept involving physicians in different specialties or groups, such as the doctor who treats the patient after us or the doctor who referred the patient to us.  However, when stripped down, the concept of “continuity of care” addresses any situation when multiple providers, whether inside or outside a practice, treat one patient for the same or related medical issue.  Like puzzle pieces, the information from each provider needs to join together so that all relevant information for the ongoing medical issue is continuously available to all treating providers.  If those puzzle pieces of information never join, then it may just be that the key piece of information falls through the cracks.  

Like many toddlers, 18-month-old Caroline Jones* was in and out of her pediatrician’s office with a number of common pediatric illnesses.  As is customary in pediatric practices, she saw several of the practice’s physicians throughout her numerous appointments.  Caroline had recently been struggling with eczema and contact dermatitis, but the condition was just getting worse.  Topical creams did not provide enough relief, and, during her July 26th appointment with Dr. Carpenter, her mother reported that Caroline had been scratching the eczema patches.  Dr. Carpenter diagnosed Caroline with impetigo and prescribed a course of Bactrim for 10 days.  

Mother brought Caroline back to see Dr. Carpenter on August 3rd, complaining of fever, some transient episodes of disorientation, and the worsening appearance of the rash on her daughter’s face.  Mother also informed Dr. Carpenter that Caroline had recently been bitten by a tick.  Dr. Carpenter examined Caroline and discovered otitis media in the right ear.  He described her face as having annular patches on the cheek.  Tinea corporis was felt to be the cause of the rash on Caroline’s face and an antibiotic was prescribed for her ear infection.

Caroline’s mother brought her daughter back to the office the following morning and saw Dr. Carpenter’s partner, Dr. Reynolds.  Mother reported that Caroline had a high fever overnight and a “splotchy” face that morning.  During the August 4thappointment, Dr. Reynolds described the rash as maculopapular.  He also saw the right otitis media.  Dr. Reynolds suspected Caroline was experiencing an allergic reaction to the antibiotic Dr. Carpenter prescribed the day before, so he substituted another antibiotic and counseled the mother that it would take one to two days to see clinical improvement in the allergic reaction.  Dr. Reynolds did not follow up on the mother’s prior report of tick bite because he was not aware of it.  Dr. Reynolds later admitted that he did not read Dr. Carpenter’s note of the prior day’s appointment.              

Twice that evening, Caroline’s mother called the practice reporting that her daughter’s fever persisted and the rash remained unchanged.  During the second phone call, an appointment was made for the next day.  Instead, the mother ended up taking Caroline to another pediatric practice and never returned to see Dr. Carpenter or Dr. Reynolds.  Tragically, Caroline was diagnosed with ehrlichiosis four days later, dying from the infection two days after the diagnosis was made.  Her mother subsequently filed a lawsuit against Dr. Carpenter, Dr. Reynolds, and their practice.  The case was tried, and the jury awarded Caroline’s mother a substantial verdict.   

Although it was not recognized at the time, Caroline’s mother gave Dr. Carpenter the key piece of information necessary to solve Caroline’s impending medical crisis during the August 3rd appointment.  Then, when Caroline returned the next day with worsening symptoms, Dr. Reynolds did not read the note of the prior day’s office visit and never knew to include the history of recent tick bite with the information that he used when treating Caroline. 

It is unknown whether ehrlichiosis would have been diagnosed earlier if Dr. Reynolds knew that the mother told Dr. Carpenter about the tick bite.  However, if Dr. Reynolds had read his partner’s note, the lawsuit would have been imminently more defensible.  This is a simple, common sense practice point: to ensure the continuity of the patient’s care, the provider should review the documentation discussing the patient’s recent, relevant care.  It is often this kind of simple task, when not performed by a defendant-doctor, that a jury cannot understand or forgive.  In this case, Caroline’s mother reported the tick bite only to Dr. Carpenter, and did not repeat the report to Dr. Reynolds.  Perhaps she believed that, since she had already reported it to one doctor, she did not need to advise any subsequent provider.  It is easy for a jury, comprised of lay people who are patients themselves, to understand why a plaintiff attorney blames a defendant-doctor for neglecting to perform such a simple task – and to agree.   

As a footnote, when the mother transferred Caroline’s care to another practice, she unwittingly caused the second disruption in the continuity of her daughter’s care.  The new pediatrician was charged with trying to solve the mystery of Caroline’s illness after being thrust into the middle of its course.  The mother did not repeat the history of tick bite to the new provider until August 8th.  By that time, the infection had progressed past the point where Caroline could be saved.  An abrupt transfer of care can result in crucial information never reaching the new provider who is starting from the beginning with a patient who may not have much time left – and this is a lesson for the patient in all of us.

* Names of patients and physicians have been changed