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Discontinuous care: the leading cause of medical malpractice insurance cases

By Barry Bialek, MD – Senior CoverMD Contributing Editor

Summary

In this article, Dr. Bialek discusses Transient Ischemic Attack (TIA) to highlight instances of discontinuous care in the ER. Discontinuous care is the leading cause of medical malpractice cases and the article talks about how compassionate healthcare benefits both the patient and the physician.

The decisions we make have, literally, life or death consequences.

There’s a reason hindsight is 20/20 — we look back on a situation with the outcome already known, and know precisely what we should have done to achieve the best results. In most situations in our lives, hindsight doesn’t matter, but physicians have the unique privilege – and responsibility – of knowing that decisions we make have, literally, life or death consequences.

An elderly man has a Transient Ischemic Attack (TIA), but his denial delays transport to the hospital. Once he arrives, the ER doctor doesn't refer immediately for definitive treatment – and the once-vibrant patient suffers a devastating stroke.

Ten percent of people suffering a TIA will suffer a stroke within the next 90 days. Half of these strokes will occur within the first two days.


See the disease process from your patient's point of view

As a physician, one of your most powerful attributes is compassion – empathy in action. Of course, to be a good doctor you also need skill and knowledge. But empathy – seeing the disease process from your patient's point of view – creates a return that delivers more than you may think.

When we care, we pay better attention. Not only do we give more effective medical advice, we also prevent the number one cause of medical malpractice cases: discontinuous care.

I've practiced family and emergency medicine in both rural and urban centers. Over the past ten years, I've also been the in-house medical consultant at a well-known personal injury firm, reviewing cases and advising attorneys. The following parallel real-world scenarios illustrate the case for compassionate continuous care — to the tune of $3.4 million.

Transient Ischemic Attack (TIA) – How urgent is it?

Henry

Henry was 71 and had been retired for a few years, but still golfed three days a week, read the Times every day, and loved to travel in Europe. He woke up “feeling funny” early Saturday morning. He noticed that his thinking was fuzzy, and he couldn’t access the right words to describe his condition. Sarah, his wife of 46 years, was asleep beside him. Henry didn’t want to alarm her, so he rolled over and tried to go back to sleep. No dice – Henry knew something was wrong and, although he didn’t want to admit it, he was afraid he had suffered a stroke.

After lying awake for an hour, Henry woke Sarah. As soon as she heard him fumbling for words, she called 911. The ambulance crew arrived four minutes later and transported Henry to a community hospital in northern Michigan. Henry was examined by Dr. A, one of the local family physicians who staffed the hospital’s emergency room. By the time Henry arrived at the ER, he was beginning to find the right words. Within an hour, he was communicating normally.

Dr A performed a history and physical exam, finding only expressive aphasia that had completely resolved while Henry was still in the ER. (Henry’s cardiovascular exam, including auscultation of the carotid arteries, was unremarkable.) Dr A ordered a head CT, which was read as normal. Blood work and EKG were also normal. Ultrasound was not available.

Dr A discharged Henry after four hours in the ER, and set him up for follow-up visit the next week by the local neurologist. Sadly, Henry suffered a massive stroke the following day, due to a left carotid artery plaque that embolized to – and blocked – Henry’s left middle cerebral artery, permanently injuring his left temporal lobe. Henry survived, but only as a shell of his former self. No more rounds of golf; no more trips to Paris with Sarah. He was paralyzed on his right side and mentally incompetent.

Sarah was understandably devastated and extremely upset, but because she had no real relationship with Dr A, she was also vengeful. In court, the jury awarded $3,400,000. The insurance company settled after trial for $2,500,000.

Martha

Martha's story is similar, but has a different ending.

Martha and Chuck had been married for 38 years. They were at an annual Labor Day barbecue in their northern Ohio neighborhood when her left arm went suddenly numb and weak, causing her to drop her plate. Chuck called an ambulance, which arrived in five minutes and transported Martha to the local community hospital, where she was treated by Dr B.

Dr B suspected a stroke and performed an appropriate history and physical exam, identifying an enlarged and tender right calf (due to a fall the previous week), as well as a previously undiagnosed cardiac systolic murmur. The rest of the exam was normal, except for a weak left arm. Over the next two hours, while still in the ER, Martha’s left arm strength returned to normal.

Dr B diagnosed Martha with a TIA (transient ischemic attack), due to a deep venous thrombosis of her right calf deep that embolized to the right side of her heart, passed through a previously undiagnosed ventricular septal defect, and finally lodged in her right middle cerebral artery.

Knowing the significant risk of stroke after a TIA and concerned that Martha face this risk, Dr B transferred Martha emergently to a nearby trauma center. She was quickly diagnosed and treated medically and surgically and continues to enjoy holiday barbecues with Chuck.


Compassionate care can help deter long and painful litigation

Compassionate care is usually more attentive – which improves continuity of care and patient outcomes. However, even with compassion, outcomes are sometimes poor. The two stories above both begin with a TIA – a potentially preventable disease. Their endings are vastly different: one patient lives in a skilled care nursing home with a multi-million dollar malpractice settlement; the other is still enjoying her golden years.

Compassionate care isn't about "faking it" to avoid a lawsuit. Caring interactions with our patients give us deeper internal rewards and promote continuous care and improved health. The fact that compassionate care could also help deter long and painful litigation down the road is a secondary, and very real, benefit.


A simple score (ABCD) to identify individuals at high early risk of stroke after TIA
The Lancet, Volume 366, Issue 9479, July 2, 2005, Pages 29 – 36
Age > 60 years = 1
Blood pressure SBP > 140 or DBP > 90 = 1
Clinical Unilateral weakness = 2; speech disturbance w/o weakness = 1; other = 0
Duration > 60 minutes = 2; 10 – 59 minutes = 1; < 10 minutes = 0

An excellent overview of transient ischemic attacks (TIAs) by the American Academy of Family Physicians
Transient Ischemic Attacks: Part I. Diagnosis and Evaluation
• www.aafp.org/afp/2004/0401/p1665.html
Transient Ischemic Attacks: Part II. Treatment
• www.aafp.org/afp/2004/0401/p1681.html

Patient education on TIA by the Mayo Clinic
• www.mayoclinic.com/health/transient-ischemic-attack/DS00220


About the Author

Barry Bialek M.D. - CoverMD.com Senior Contributing Editor
Barry Bialek, MD

Barry Bialek, MD is a board-certified family physician living in Boulder, Colorado. His practice includes both family medicine and emergency medicine. For the past 10 years, Dr. Bialek has served as the in-house medical consultant to one of the most successful plaintiff's personal injury law firms in the US. His job was to advise on every medical step of every medical malpractice case. This gives Dr. Bialek a unique perspective on medical malpractice and how best to avoid it.

Dr. Bialek has held clinical faculty positions with the departments of family medicine at both the University of Toronto (Canada) and the University of Arizona. Dr. Bialek is currently a member of the faculty of the University of Colorado, College of Engineering, where he teaches his other passion: sustainable community development in Nepal.



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