Physician Legal Review & Commentary

$3 million verdict awarded for failure to follow-up, warn of risk of exertion in light of cardiac condition

By Jonathan D. Rubin, Esq.
Partner
Kaufman Borgeest & Ryan
New York, NY

Sandra L. Brown, Esq.
Associate
Kaufman Borgeest & Ryan
New York, NY

Leanora Di Uglio, CPHRM, CPHQ
Corporate Director, Clinical Risk Management
Health Quest Systems
1351 Route 55
Lagrangeville, NY 12540

News:In March 2009, a 31-year-old husband and father of two young sons was evaluated by a board-certified cardiologist with complaints of increasing episodes of chest pain radiating into his arm. The cardiologist, believing the condition was stable, ordered a nuclear stress test be performed within 1-2 weeks. The cardiologist did not advise plaintiff to avoid physical exertion until the stress test was performed. One day before the nuclear stress test was performed, the patient was found unconscious after a sexual encounter. He died at an area hospital an hour later of coronary artery disease. At trial, the jury found the cardiology group and cardiologist acted negligently in their treatment of the patient and awarded $5 million award to the patient's wife and two sons. The patient was found comparatively negligent, and the award was reduced by 40% to $3 million.

Background:On March 5, 2009, a 31-year-old husband father of two young sons presented to a board-certified cardiologist with a medical history significant for uncontrolled hypertension, hyperlipidemia, and sleep apnea. Plaintiff had complaints of increasing episodes of chest pain radiating into his arm. During the appointment, the cardiologist reviewed echocardiogram test results taken about a month earlier, which showed elevated calcium deposits in his coronaries, enlarged heart ventricles, and aortic regurgitation. The cardiologist's impression of the patient's conditions were:

  • chest pain with an elevated calcium score, suspicious for underlying coronary artery disease;
  • hypertension with left ventricular hypertrophy with normal diastolic function and no evidence of congestive heart failure;
  • hyperlipidemia with LDL of 140;
  • hypertension.

The cardiologist believed that the patient's condition probably was due to his heart, but believed that it was stable. Accordingly, the cardiologist ordered the patient undergo a thallium stress test on the first available appointment and go to the emergency department if his symptoms lasted more than five minutes.

The patient scheduled an appointment for the Thallium stress test for March 13, 2009. On March 12, 2009, one day before the patient was supposed to undergo the stress test, plaintiff had a sexual encounter that included a friend and a woman who was not his wife. After having sexual intercourse multiple times, the woman found the patient unconscious. Emergency medical services were called and upon arrival found the patient unconscious, without pulse and with no spontaneous respiration. Resuscitative efforts were initiated, and the patient was transported to the hospital where he was pronounced dead. An autopsy that included toxicology screening revealed 90% occlusion of the left anterior descending and right coronary arteries, ventricular interstitial fibrosis biventricular hypertrophy, and mild cardiomegaly.

The patient's wife filed suit on behalf of the patient's estate against the cardiology group and cardiologist, and she asserted negligence and medical malpractice. At trial, plaintiff's expert testified that the patient's condition required an immediate and urgent workup. Plaintiff further claimed that the defendants did not instruct the patient to discontinue physical activity until the completion of his cardiac work-up. The defense contended at trial that the cardiologist did warn the patient not to physically exert himself until after the stress test.

The jury found that the cardiology group and cardiologist acted negligently in their treatment of the patient. Specifically, the jury found that the defendants should not have allowed the patient to go home after his last appointment and should have administered a cardiac workup and stress test immediately.

The jury awarded $5 million against the defendants, the cardiology group and cardiologist. The patient was found comparatively negligent, and the award was reduced by 40% to $3 million.

What this means to you: The case scenario describes the wrongful death of a 31-year-old man who was being treated for risk factors associated with coronary artery disease, i.e., hypertension and hyperlipidemia, while undergoing further diagnostic evaluation to determine the extent of his disease. Plaintiff's prevailed with their argument that the physician failed to meet the standard of care by not timely evaluating the decedent's new onset of exertional chest pain and through his failure to appropriately instruct the decedent not to participate in strenuous physical activity until his cardiac work up was completed.

A challenge many risk managers face is determining the best risk mitigation strategy to use when the alleged malpractice focuses on a physician's medical decision-making process. Reviewing compliance with clinical best practices might identify issues with a physician's clinical performance; however, in this case the diagnostic workup recommended by the defendant physician was in accordance with clinical protocols. Risk managers also can review physician documentation to determine whether the physician recorded the decision-making process. In this case, the medical record concisely reflected the defendant's thought process: need for further cardiac workup (i.e., Thallium stress test), treatment of identified risk factors (i.e., lipid-lowering medications, aspirin), and disease prevention strategies, (i.e., health, diet and weight).

Risk managers need to identify and mitigate other factors that might have contributed to this unfortunate outcome, specifically communication between the physician and office staff, and patient education. The defendant physician did advise the patient to schedule the Thallium stress test on the first available appointment, but were communication channels between the physician and office staff in place to notify the physician that the first-available appointment was eight days later? There might be opportunities through the appointment or scheduling programs to alert physicians when diagnostic or follow-up appointments have been made.

The other area that should be given attention as a risk mitigation strategy is the routine use of patient education literature. Although there was evidence that the defendant physician provided instructions to the decedent during their last office encounter, additional patient education literature would reinforce and perhaps expand the content of the information provided by the physician. Including patient education as part of any patient encounter process can assist with improving a patient's health behavior and status and would assist with minimizing the providers risk exposure.

Coronary artery disease does not discriminate among gender, ethnicity, or financial status, as evidenced by its status as the number one cause of death for men and women in the United States. The National Institutes of Health estimates approximately 400,000 people die from coronary artery disease per year. It is no wonder that comprehensive efforts are being made by the healthcare industry to improve the prevention and treatment of this deadly disease.

Reference

2010 WL 8705746 (Ga. State Ct. No. 10C-02212-4, 2010).