American College of Physicians: Internal Medicine — Doctors for Adults ®


Malpractice case study: Communication breakdown

From the September ACP Observer, copyright 2006 by the American College of Physicians.

A 53-year-old man was seen by his primary internist for indigestion. His condition had not improved with the usual antacid therapy. The patient was an obese heavy smoker who had a long and well-documented history of hiatus hernia and esophageal achalasia. Hospitalization was ordered and an acute inferior myocardial infarction was documented. He was then transferred to a tertiary care center, where angiography demonstrated a totally obstructed right coronary artery and significant stenosis of the proximal left anterior descending. Suffering ongoing chest and abdominal pain, the patient was hospitalized for more than two weeks at the referral institution. Gastrointestinal and psychiatry consultations were obtained in addition to the extensive cardiac evaluation.

Ultimately, the patient’s pain was believed to be primarily cardiac in origin. Despite this belief, medical therapy alone was recommended. The patient was referred back to his primary physician, who again hospitalized him after he presented with additional chest pain. The admitting note indicated that the physician thought the patient did not have surgically correctable coronary artery disease, suggesting that he did not see a report from the referring cardiologist that recommended surgery be considered if there was recurrent chest pain. After 24 hours of observation, the patient was discharged. He died four days later of an acute MI.


“In this case, we have professional negligence, since it didn’t seem to be appreciated by either the primary care physician or the cardiologist that his ongoing pain was cardiac in origin and therefore he needed re-evaluation in terms of being a candidate for surgery,” said David Troxel, MD, senior vice president and medical director for The Doctors Company. “The primary care physician should have realized that when he had the second episode of chest pain, he needed to be re-evaluated at that point. At the very least, he should have gotten back in touch with the consulting cardiologist.”

Better communication might have avoided the bad outcome in this case, he continued. “You could effectively argue in court that if the cardiologist’s written report was read by the primary care physician, the re-evaluation would have occurred and perhaps the patient wouldn’t have died.”

Alice G. Gosfield, Esq., a Philadelphia-based attorney specializing in health law, calls such failures the “dropped baton problem,” when physicians for one reason or another neglect to follow up on information. This could take the form of failing to follow up on notes from a referring physician or one doctor’s failure to address abnormal test results ordered by another doctor for a patient on his service in the hospital.

The increasing fragmentation of medical care in general contributes to communication problems, noted Alan Lembitz, MD, vice president of risk management for Denver-based COPIC Insurance Co., which insures 7,000 physicians in Colorado and Nebraska. “As we have more subspecialists, more hospitalists, more intensivists and less single primary care physicians in charge of someone, we see breakdowns in information.”

Universal electronic medical records would be a huge step toward remedying this problem, he continued. “It would provide a central repository so the patient can have access to the three or four specialists saying different things. No one in a paper system has a complete database related to the patient and you can’t possibly take the time to construct one.”

Source: The Doctors Company, a Napa, Calif.-based national medical malpractice carrier.


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