Medical Malpractice Lessons From an Internal Medicine Physician

When faced with a potential new malpractice case, plaintiff attorneys often wonder about the merits of the case, while the defense seeks confirmation of its limits. Bad outcomes or emotional letters by grieving family members do not always correlate with the merits of a case. Finding the right expert and understanding the background and context about how these mistakes occur is often a critical factor.

If I were to teach a class to help doctors avoid common medical malpractice mistakes, I would help them to understand five basic principles. Based on my experience as an expert, I have observed these common errors that often seem to be the reason for many mistakes.

The problem is that most doctors are in a certain amount of denial. Yes, there are medical mistakes and medical malpractice, but their perception is that those mistakes are made by bad doctors. In baseball, a hitter would be proud to say they got a hit one out of three at-bats. A series of strike outs would merely be considered a slump. On the other hand, a doctor would lose his license with that record. We are expected to be perfect. As a result we do not typically organize our continuing medical education around mistakes; it is assumed that we do not make mistakes. And yet, the Institute of Medicine says that mistakes lead to 98,000 deaths per year. This is exceeded only by heart disease and cancer. Given my perspective about why doctors make mistakes, I don’t think these numbers will decrease anytime soon.

So, what are these five basic principles of good medicine?

1. When an emergency room doctor makes a diagnosis, it’s an opinion, not necessarily the final diagnosis.

Too many times, I have seen the admitting doctor duplicate the history and physical results noted by the ER doctor, and therefore jump to the same conclusions. For example, the patient comes in with altered mental status, the ER doctor orders a brain CT scan which comes back normal and assumes this is dementia and some minor exacerbation. The reality, however, may be that the patient had a stroke. Which a better history and a more careful neurological exam would have identified.

During my medical residency training, an ER attending physician once pointed out that there are only two questions which need to be answered in the ER. He went on to say that it shouldn’t take more than 15 minutes to answer each of those questions. Those questions were:

1. Is this a surgical case or a medical case?
2. Do I need to admit the patient or can I send them home?

Of course, nowadays many patients spend the better part of a day in the ER getting various imaging studies. However, the admitting doctor still needs to be held to a higher level of sophistication, based on their experience and training. They should be able to arrive at a more accurate and more complete diagnosis than the ER physician.

2. Respect the vital signs.

This applies more for outpatient primary care physicians than hospital physicians. They assume there is a reason for admission to the hospital and are more apt to consider sepsis syndromes. But, in the outpatient setting, it is easy to become inured by all the mild illness one sees. But not all colds are viruses and not all fevers are colds. Often the best alerts a physician has is to take vital signs. Is the patient tachycardic? Is there an increased respiratory rate? Is there a fever? Most office doctors don’t check all four of the basic vital signs. So it is even more important to respect any abnormal results, as they could be the best early clue to pneumonia. Furthermore, a patient without typical ‘cold’ symptoms (eg cough, runny nose, sore throat) and a fever should make one consider less common syndromes like endocarditis or urinary sepsis.

3. Complete the physical exam.

Yes, doctors have a finite amount of time and a lot to do; however, it’s not acceptable to short change the physical exam. Before electronic medical records, a typical physical exam might report ‘Lungs, Heart, and Extremities’. Since electronic records have taken over, there is often a complete reported physical, and it would appear that the doctor did a stellar job. But, sometimes, the truth comes out later, that in reality, certain body parts were not actually examined.

I remember a case where the hospital doctors admitted a patient with fevers, general body aches, fatigue, and a substantially elevated white blood count. They ruled out pneumonia from the chest x-ray, and ruled out urinary tract infection from the urinalysis, but were unable to determine where the infection was coming from.

So, they consulted a surgeon and asked him to do a pelvic exam, wondering about the possibility of Fournier’s gangrene, a serious pelvic infection. His consult came back, ‘No, everything looks good down there, but I noticed one of her knees was very red and quite swollen; I think she has a septic knee.’. This was the correct diagnosis. However, the delays allowed complications and, despite antibiotics, the infection had already spread to her hip. She eventually required a very prolonged period of intravenous antibiotics, experienced limited mobility, and required a knee and hip joint replacement. A good initial physical exam could have improved her outcome.

4. Don’t dismiss abnormal findings.

Preconceived narratives are a powerful force. The media recognizes this, and as a result news is often slanted one way or another. In the medical field, this is referred to as confirmation bias. As doctors in primary care, we often work as problem solvers. But, in doing so, we form hypotheses based on the available information. If certain clues lead us to anchor ourselves one way or another, we might not have the flexibility to switch gears and consider something else.

For example, a relatively healthy middle aged man presents to his primary care physician with non-specific fatigue. Routine blood tests identify a mildly low white blood count, platelet count, and a mild anemia. Because the doctor is stuck on the idea that this person appears mostly healthy, those abnormal counts are dismissed and considered to be related to a mild ‘viral illness’. Yet, what he really has is Hairy Cell Leukemia, and a bone marrow test is needed for diagnosis.

I had a case where the primary care doctor saw a patient with textbook angina symptoms. The problem was, he developed his symptoms of exertional chest tightness and shortness of breath in the context of a recent respiratory illness. Furthermore, he was also being considered for a workers’ compensation claim, since he was concerned about his work as a utilities company field inspector and possible exposure to West Nile virus. Initially, the primary care doctor was stuck on the idea of West Nile virus, and delayed the workup for cardiac disease.

Furthermore, once he did refer the patient to a cardiologist, although the cardiologist identified this classic history suggesting coronary artery disease, this particular cardiologist was somehow motivated to utilize his own in-office nuclear stress test. When the results came back non-diagnostic, he inappropriately labeled the patient as having non-cardiac chest pain. Over the next couple years, despite repeated typical angina symptoms, his primary care doctor offered a series of alternative flawed diagnoses to explain the symptoms; too much stock was put in the false negative results from the original cardiologist. Amazingly, this patient even underwent gallbladder surgery, despite the absence of gallstones on an ultrasound. The denial of his coronary artery disease symptoms resulted in unnecessary surgery, and the patient died shortly after that surgery.

5. Doctors must communicate with the patient and their family.

Although this seems basic, it appears that this rule gets violated quite often. Good communication can often excuse doctors from being sued. But, in my experience as a medical expert, absent or minimal communication seems to be the rule. In this context, any bad outcome raises the ire of the family and a malpractice suit seems to be the next logical step. It is easy to become stuck on a diagnosis or particular clinical outcome. Physicians may dig in their heels and resist family suggestions; after all we were the ones who went to medical school. However, family members may not be that unsophisticated and their thoughts should be registered. After all, they have also been thinking about the patient’s illness, looking for answers on the internet, and discussing options with other family members. Why shouldn’t doctors get their input?

The practice of medicine is an evolving science. What was known even twenty or thirty years ago may seem completely absurd now. Doctors have a duty to their patients to maintain continuing medical education and to become familiar with today’s standards. Understanding the context for observed medical mistakes is also useful to attorneys.