Lawsuits against primary care physicians entail drug errors and missed diagnoses
Most malpractice claims against primary care doctors are the result of missed or delayed diagnosis or drug errors, according to an analysis of 34 studies.1
Among adults, the most common alleged missed diagnoses were cancer, heart attack, appendicitis, ectopic pregnancy and broken bones. Among children, the most common alleged missed diagnoses were meningitis and cancers.
"The majority of healthcare occurs in primary care, so it is important to have a greater understanding of where claims arise in this setting," says Emma Wallace, MB, BAO, Bch, the study's lead author and a clinical research fellow at Royal College of Surgeons in Dublin, Ireland.
Primary care doctors must identify patients with serious underlying disease when faced with undifferentiated presentations in a setting of care where the prevalence of serious disease is lower when compared to the specialist setting, notes Wallace. "Clinical risk management systems and educational initiatives could help by focusing on diagnostic difficulties and highlighting conditions commonly leading to primary care claims" such as women with heart attacks presenting atypically says Wallace.
Most claims against primary care physicians involve failure to timely diagnose cancer or cardiovascular disease, notes Mark L. Graber, MD, FACP, senior fellow at RTI International in Research Triangle Park, NC, and founder and president of the Society to Improve Diagnosis in Medicine. "Make sure your patients are up to date on recommended cancer screenings," Graber advises. "Be sure to follow up on any abnormalities detected." Graber recommends these practices:
• Consider obtaining a second opinion if there is major diagnostic uncertainty.
"Second opinions may be one of the best strategies to detect diagnostic errors," says Graber. This step can prevent errors that can lead to malpractice claims and also clearly indicate some uncertainty in the diagnosis that was addressed by requesting additional advice, thus making claims more defensible if they do occur, he says.
• Don't trust diagnoses presented by the patient or other physicians without rethinking the case.
• Make the patient your partner in diagnosis.
"Explain that we are always playing the odds," says Graber. "Make sure they know when and how to get back to you if their symptoms change or if they don't respond to treatment."
• Document your thinking, and point out areas of uncertainty and where you've made assumptions.
If several different diagnostic possibilities are reasonable, which is often the case, acknowledge that the diagnosis is not certain, advises Graber.
"Justify your subsequent actions accordingly, whether additional tests, consultation, trial of treatment, or wait and see,'" he says.
• Survey patients to obtain feedback on your communication style, and take actions to improve if you don't score well.
Graber says focus groups consisting of several patients, staff members, and someone with expertise in patient relations are a good way to explore what the physician does well and where improvements are needed.
"Communicating effectively with your patients is probably the most important factor in decisions to file a suit," says Graber.
1. Wallace E, Lowry J, Smith SM, et al. The epidemiology of malpractice claims in primary care: a systematic review. BMJ Open 2013; 3:e002929; doi:10.1136/bmjopen-2013-002929.