Episode 085: Not Everything Is As It Seems

Speaker 1: You're listening to Your Practice Made Perfect. Support, protection, and advice for practicing medical professionals, brought to you by SVMIC. 

Brian: Hello, welcome to this week's episode of our podcast. Once again, going to have the wonderful opportunity to talk about a closed claim. My name is Brian Fortenberry. Joining me again today, voices that certainly should be familiar to you that have had the opportunity to listen to some of our podcasts before, we have Katy Smith and J. Baugh. Katy, J, welcome back once again. 

Katy: Thanks Brian.

J. Baugh: Thank you, Brian. Good to be here. 

Brian: Well, let's start as we always do, and this is going to be old hat for those folks that have heard us before, but I'm always cognizant of those new listeners that we might have and this might be their first one. Let's start by telling them a little bit about your background and your time here at SVMIC. Katy, as always, we will start with you.

Katy: Well, thanks Brian. I'm a lawyer in the Claims Department. Been here almost 13 years and in that role I manage claims for the company and also speak with physicians and their practice managers and discuss various risk, legal, management issues, and pleased to do that. 

Brian: Well, fantastic. J, tell us a little bit about your background.

J. Baugh: Well, I am also an attorney in the Claims Department, doing the same type of work that Katy does. Managing claims for the last 18 years. 

Brian: Well, as always, this is going to be very informative and I really appreciate the both of you taking time to be here. Today, we are going to be looking at a case involving a 23 year old male whom we will refer to as Michael Jones, who presented to a family practice physician, Dr. Jane Green in the year of 2016, complaining of ankle pain for several days. I believe it was three days. Mr. Jones reported that he was unaware of any injury that had happened previously to his ankle. So let's just kind of start there. Katy, how did this first appointment go when he showed up at the physician's office?

Katy: And this was his first appointment ever with Dr. Green, and a really mild complaint. Just an ankle injury, single ankle injury. Dr. Green examined him and noticed swelling and bruising of the ankle, and diagnosed Mr. Jones with an acute ankle sprain and prescribed him an anti-inflammatory. So a really relatively benign family practice visit. 

Brian: So now we've got that first visit over with Dr. Green and it seems fairly normal, as we said. So Mr. Jones returned to Dr. Green for a second time. J, was this a few weeks later, is that right? And if so, what happened on that second visit? 

J. Baugh: Well, that's right. He came back about three weeks later for his second visit. And so the complaints were very similar, continued to have right ankle pain. And so Dr. Green took an x-ray of the plaintiff's ankle and it turned out to be negative for a fracture. And so she asked the patient to continue to take the anti-inflammatory medication that she had prescribed at the first visit, and told the patient to continue to treat the ankle with rest, ice, elevation and wrapping. 

Brian: All of us that have had ankle sprains before, we know what that means, right? We just end up elevating, and putting ice, and doing all of those things. So, again, it sounds very straightforward, like nothing is happening here. But my understanding now is that a month later, Mr. Jones again returns to Dr. Green's office and I guess this is the third time. Is that right, Katy? 

Katy: Third visit. And now we've got a slightly different presentation. 

Brian: Okay. 

Katy: So Mr. Jones, now presents and he complains of constant swelling in both of his calves, and his ankles, and his feet. So it was, again, initially just on his right ankle but now we've progressed to bilateral complaints, and for the first time, the patient tells Dr. Green, "Yeah, I've had this mild and random stomach problem for the past five years." And he described it as diffuse abdominal pain, vomiting, and some weight loss. Dr. Green documented that these ongoing stomach issues sound like IBS, or irritable bowel syndrome. Doesn't do anything further really to evaluate the stomach complaint, but for the lower extremity issues she order a Doppler ultrasound, which was negative for a clot. 

Brian: So there is no clot, nothing like that. Correct, J?

J. Baugh: That's right, and because the complaint of the ankle was getting worse over time, the doctor at this visit decided to order some lab work. And so the doctor ordered CBC and CMP. The CBC was performed in the laboratory there at the doctor's office. The CMP was sent to an outside lab to be processed. And so those results were returned to the doctor's office the next day, and those results showed that the patient had a very low albumin level. 

Brian: Okay, this has been like a month and a half and we're three patient visits in now, so how does this scenario keep going forward, J? 

J. Baugh: Well, unfortunately, the chart doesn't show that any action was taken to address this very low albumin level. And, in fact, the patient was lost to follow-up for almost seven months. 

Brian: Seven months? 

J. Baugh: That's right. We have a seven month window in which we do not show the patient having ever returned to Dr. Green. However, he does come back in February of '17, and at that office visit, he complains of diffuse and sharp abdominal pain. He also complains of continued ankle swelling. So now this has been going on for several months. He complains of joint pain, fatigue, and excessive thirst. And so the patient reports that he did well initially on his iron supplement for his anemia, which is a bit unusual, because Dr. Green did not recommend or prescribe this iron supplement. So that shows that he must have been getting care from another healthcare provider somewhere else. And he also reported that he experienced a little bit of weight gain, but then he began experiencing weight loss again.

Katy: So we've got quite a change now in this patient's presentation, and Dr. Green orders and performs another CBC in her office lab, which showed low hematocrit and low hemoglobin levels. Unfortunately though, she did not order another CMP lab, and from the chart, it looks as if that lab result, which was markedly abnormal, just kind of falls off. It wasn't followed up on, no further testing was performed, no follow-up repeat testing was performed. Dr. Green diagnoses the patient with unspecified anemia, unspecified joint pain, an unspecified abdominal pain. She recognizes that she needs to rule out some potentially serious conditions like Crohn's Disease and Ulcerative Colitis. But her note doesn't at all map out any follow-up plans, any treatment pains, any further investigation. It just ends. 

Brian: At this point in our story, we don't know what is going on, but we know it's not an ankle sprain.

Katy: Something's going on.

J. Baugh: That's right. 

Katy: And something's worsening. 

J. Baugh: Yes, and it's much more than just the ankle sprain that the patient initially presented with. 

Brian: This history and physical just seems odd from the very get go. We've got a lot happening here, so what's going on next?

J. Baugh: So the next thing that happens is the patient comes back to see Dr. Green two days later. And his appointment followed a phone call that happened early in the day from the patient's girlfriend, and she reported that the patient had passed out at work that day. And the girlfriend was calling the doctor's office to say, "Should we take him to the ER, or should we bring him to your office?" And Dr. Green recommended that the patient come to the office for an evaluation. And so the patient is brought to the office, and he complains of mild abdominal pain and acute dizziness. And so the doctor's diagnosis remained unspecified abdominal pain. She prescribed a Medrol dose pack, and in her office note, she recognized the need to do further work-up soon. Now I don't exactly what that means. It doesn't tell you what the follow-up is going to be, when the work-up is going to be, and soon is too general to let you know when it's going to happen. 

Brian: How's this pan out?

Katy: So what happens to Mr. Jones is he goes home after this final visit with Dr. Green and has a sudden cardiac arrest at his home. The girlfriend was there, so she was about to call 911. Paramedics responded and resuscitated Mr. Jones, but not before he experienced a debilitating anoxic brain injury, which left him unable to care for himself or live independently. Mr. Jones was ultimately diagnosed with pancolitis, which is ulcerative colitis of his entire colon, which had progressed so severely as to render him profoundly hypokalemic, which was the cause of the cardiac arrest. So a lawsuit was ultimately filled on his behalf, and the claim was ultimately settled for a significant amount. 

Brian: Why did this outcome come to be, J? How did we miss this? 

J. Baugh: I think if you go back to the very beginning of this case, the patient's initial presentation to Dr. Green's office, you can now see that he exhibited symptoms of ulcerative colitis at his very first appointment, especially if you consider that he presented with an ankle injury that he claims he didn't know why it happened. He said that it was not because of any trauma, so that should raise some sort of flag as to what the cause of the injury was, if he doesn't recall having actually injured it. So by his third appointment with the doctor, the patient's low albumin level and this slower extremity and joint pain and all that, those were additional symptoms of this undiagnosed and progressing inflammatory bowel disease. 

Katy: Now this gentleman was very young, 23 years old, when he first starts coming to Dr. Green. So, likely, at the time she sees him she sees a 23 year old young man. He appears healthy. His complaints, at least initially, are rather mild and benign, and they do develop, but really by that third visit, they're still pretty mild. The February 2017 symptoms are certainly much more serious, but probably Dr. Green just looks at what is presented in front of her and sees a healthy, young guy with a little problem going on, and treats that issue, and looks at it in isolation.

Brian: I think back to the very beginning and keep going back to this all started with a complaint of what is believed to be a sprained ankle. 

Katy: Right.

Brian: And it's easy to sit here and look back and go, "Yeah, this turned into something else." But how many times have I or my family members or people I know had an injury and you went and they said, "Well, is anything else bothering you?" And you go, "Yeah, my head kind of hurts today from a sinus infection," or, "My belly's been a little upset over the last couple of days," and they look at me or my young family and they go, "Yeah, that's life. That's normal stuff." 

Katy: And it usually is normal stuff.

J. Baugh: That's right. In most situations, it is going to be normal to take a very simple way of treating that, but unfortunately there was a little more to it in this particular case. 

Brian: And as it didn't go away, as it kept progressing, I think that was the issue, right Katy?

Katy: Definitely, and I think you hit it on the head, Brian, when you said, looking backwards. It's this hindsight bias problem. I think that is particularly important when you're thinking about lawsuits. Everybody knows what happened to Mr. Jones by the time the lawsuit was filed. The lawyers know, the jury knows (that might ultimately try the case) and so everybody starts at the end rather than Dr. Green, who is seeing the patient in real time and does her best to treat the symptoms that she feels like he's presenting, but when you start at the end and you look backwards, and you just see all of these little dots that are developing, and growing, and worsening, and you think, "Man, don't you see what's happening?"

Brian: Right, that can be applicable to anything. Do you see this hindsight bias a lot?

Katy: Yes. And I think it makes it challenging to defend cases, especially a case like this where you have a young, normal patient who ends up with this very unusual and progressively worsening disease that ultimately doesn't kill him, but it's a terrible, horrible outcome, and it's a very sympathetic situation. 

J. Baugh: I think if this case had gone to trial, the defense attorney would have done a good job of trying to get the jury to put themselves in the doctor's shoes. You have a patient who came in with an ankle injury, and in the end we know this patient had pancolitis. I mean, what are the odds of that happening?

Brian: Yeah. 

J. Baugh: They're very, very remote. And so the challenge is to get the jury to go back to day one and to see this patient the way Dr. Green saw this patient. And so that's what you try to do, but can you do that in the end? Will you be successful in doing that at trial? And because of that, and because of some other facts in this case, the decision was made to settle it. 

Brian: So, J, what can be learned from Dr. Green's situation here on connecting these dots? Because, as you say, it wasn't easy to get to the diagnosis that ended up being the issue, so how do you deal with that? 

J. Baugh: Well, I think there are a few tips to take away from this case. One would be to be very attentive when the patient tells you what his or her complaints are and the presentation during the encounter, and during every encounter that happens after that, and to try to put all of that together in a timeline. Because you might know more about the patient's situation if you look at all of the presentations instead of looking at each one individually. Another point would be to be thorough when you're writing in the record for the encounter. What your diagnosis is, what your treatment is, what your plan is, be very specific about those sorts of things rather than the general types of entries that we saw in this case. If the patient refuses the care that you have recommended, document that that happened. Document why the patient did that, if you know that. 

So just make sure that the charting is very thorough in that regard. If patients come back repeatedly with ongoing symptoms, worsening symptoms, that's what we saw in this case, especially with the patient's ankle situation. Dig a little bit deeper into what is going on with this patient. And also, at some point, you need to consider whether you're going to refer the patient for a second opinion. Should you send the patient to a specialist? Is there some other new way of trying to treat this patient for what they have? You need to make sure that you've got a good reminder system in place when it comes to outstanding labs and test results and that sort of thing. I've often heard it said that if a lab or a test is important enough for you to order, then it's important enough for you to follow-up to see what the results of those labs or those tests are. So be sure that you've got some sort of system in place to do that.

You'll also need to have a good system in place for following up with patients, whether they're in need of follow-up care, future appointments, that sort of thing. And make sure your staff schedules those visits. If the patient refuses the appointment, be sure to document that the appointment was refused, why the patient decided not to come, (if you know that sort of thing) and just make sure that all of your staff is on the same page about what that system is, so that a patient doesn't get lost to follow-up care. 

Katy: I would also say if you've got a patient who mentions a different provider, care that you didn't prescribe - in this case it was the iron for his anemia, follow-up on that. Don't just let that thread run away. Follow-up with patient. If the patient identifies a physician, get those records. You're going to want the complete picture. And J really mentioned this, but take the time to sit back and perform a more comprehensive review of your patient's office visits. Don't just go visit to visit on these patients that keep returning with the same or with worsening symptoms. 

J. Baugh: Yeah, if you're the primary care physician like we have in this situation, you need to get a complete picture of what's going on with the patient. And so, as Katy said, when you have this iron supplement thing going on, you really need to follow up on that. Find out who prescribed that, why it was prescribed - that sort of thing - to make sure you have a complete picture of what's going on with the patient. 

Brian: Guys, I can't tell you how much I appreciate you being here. Unfortunately, we have a situation that is a tragic outcome here. Hopefully, it's these types of issues that we can use to learn from, and I think both of you've done a fantastic job today helping us walk through that. As always, thanks guys for being here.

Katy: Thank you.

J. Baugh: Thank you. 

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry. Listen to more episodes, subscribe to the podcast, and find show notes as svmic.com/podcast. 

The contents of this podcast are intended for informational purposes only and do not constitute legal advice. Policyholders are urged to consult with your personal attorney for legal advice, as specific legal requirements might vary from state to state and change over time. All names in the case have been changed to protect privacy.