Patient’s lack of follow-up coming up in missed MI claims
There is a whole new level of burden’ on healthcare providers
The physician needs to do absolutely everything possible to be sure the patient follows up. If you can’t reach the patient, you need to send the police."
This statement was the general content of an expert witness who testified during a successful medical malpractice trial alleging missed myocardial infarction (MI), reports Joan Cerniglia-Lowensen, JD, an attorney at Pessin Katz Law in Towson, MD.
"That is the type of testimony physicians are faced with in court," she says. "There is a whole new level of burden being put on the provider to ensure the patient follows up."
Cerniglia-Lowensen has seen several successful malpractice claims alleging missed MI that involved lack of follow-up on the part of patients.
"Plaintiff attorneys are pretty successful in getting experts to say that physicians are responsible for making sure there is adequate follow up and that this is the standard of care," she says.
Several missed MI suits recently were settled even though the care was appropriate. These settlements were due to bad outcomes and "the sympathy factor that could result in a verdict against the physician," she says.
Cerniglia-Lowensen says good documentation by physicians of what information they were told by the patient, what testing they recommended, and their thought process makes claims alleging missed MI more defensible. "Many MIs present in an atypical fashion. If the patient says, I’ve had this problem before, and it was determined to be gastroesophageal reflux, and I have a confirmed diagnosis of that — all of that makes the case significantly more defensible," she says.
One of Cerniglia-Lowensen’s clients, an urgent care center, has a system in which every patient with follow-up recommended is called the next day by a nurse or medical assistant. If the patient can’t be reached after several calls, a certified letter is sent stating, "You were evaluated at Center X, and we referred you on to Y. Please call us and let us know the outcome of your visit."
"It doesn’t always insulate them [from liability], but it’s probably the best system I’ve seen for that," says Cerniglia-Lowensen.
Previous "normal" workups
Consider the case of a female in her 50s with multiple cardiac risk factor who presents with recurrent syncope, but has no chest pain or other exertional symptoms. A stress test is equivocal, with a mild inferior wall defect that is thought to be artifact.
No angiogram is thought to be indicated, but four months later, the patient has cardiac arrest and is found to have 90% blockage. The cardiologist is sued for failure to perform angiogram, and the case is settled.
This case includes several common allegations in successful malpractice claims alleging failure to diagnose heart attack, says Sandeep Mangalmurti, MD, JD, a cardiologist at Bassett Heart Care Institute in Cooperstown, NY, and a member of the American College of Cardiology Board of Trustees Work Group on Medical Professional Liability Insurance.
"Another example of a similar lawsuit was failure to prevent MI due to [3-vessel coronary artery] disease," says Mangalmurti. "There was a normal’ stress echo after chest pain several months earlier."
Mangalmurti is aware of multiple malpractice cases involving patients with moderate risk factors and a recent mildly abnormal ischemic workup. "The patient presents with new onset chest pain and is found to have plaque rupture," he says. "The cardiologist is then sued for an improperly performed’ or incorrectly read’ angiogram or stress test."
Mangalmurti recommends that physicians:
• Be careful with patients with atypical symptoms, such as syncope, as this area can have increased liability exposure.
• Bear in mind that previous ischemic workups that are reportedly "normal" might create a false sense of security that there is no cardiovascular disease.
• Remember that patients with negative ischemic workups might not understand the continued risk of plaque rupture.
"A normal stress test or angiogram does not mean you will not have a future myocardial infarction," says Mangalmurti. "This fact should be explained clearly to patients." F