LAW: A difficult case: a noncompliant patient with a battery of symptoms

LAW: A difficult case: a noncompliant patient with a battery of symptoms
Ann W. Latner, JD
June 16, 2010

Dr. R, 52, was a rheumatologist with his own solo practice. Many of his patients came from referrals. One such patient was Ms. V, 48, who had been referred by her gynecologist after she began experiencing joint pain. During her first visit, Dr. R administered several diagnostic tests, including blood tests and a urinalysis. One test yielded a false positive result for syphilis, and another showed the presence of an antinuclear antibody. Dr. R recognized these results as two of the 11 criteria used to diagnose lupus, but to make such a diagnosis, four criteria must be present. Ms. V's urinalysis, however, did not indicate any kidney disorder, another lupus criterion. After the initial visit, Dr. R diagnosed Ms. V with degenerative arthritis. He wrote a letter to the referring physician stating that while Ms. V lacked the necessary criteria for a diagnosis of lupus, she should continue to be monitored for any changes in her symptoms that might lead to a more definitive diagnosis.

Four months later, at a follow-up visit, Dr. R diagnosed the patient with inflammatory arthritis, another criterion for lupus. Over the next two years, Dr. R continued to treat the patient. He performed regular physical examinations and blood tests, but did not do a follow-up urinalysis.

Lingering difficulties

After two years, the patient began experiencing hair loss, and went to an endocrinologist. The endocrinologist performed, among other tests, a urinalysis, which was positive for protein, indicating a renal problem. The endocrinologist told Ms. V to follow up with Dr. R, and he asked his secretary to fax the lab results to Dr. R. Only the endocrine results were received, not the urinalysis results, however. Ms. V did not follow up with Dr. R, and in fact did not see him until three months later, when she returned with a complaint of swollen feet and ankles. At that point, Dr. R performed a urinalysis, which was positive for renal disease. A biopsy confirmed that Ms. V had lupus, specifically lupus nephritis.

Dr. R prescribed cyclophosphamide, but Ms. V told him that she wished to discontinue it after a few weeks because she felt it was contributing to her hair loss. Dr. R then prescribed azathioprine and prednisone, but the patient reduced the dosage herself because she did not like the effects the medications were having on her face. The patient's kidneys began to fail, and after five months of dialysis, she received a kidney transplant.

After she recovered, Ms. V contacted a plaintiff's attorney. “I want to sue Dr. R for malpractice,” she told the attorney. The attorney had Ms. V's records examined by a medical expert who concluded that had Dr. R performed a urinalysis earlier, the disease could have been diagnosed before it had progressed as far as it did. “I'll take the case,” the attorney said.

The case proceeded to trial, at which both sides offered the expert testimony of their own rheumatologist. Ms. V's expert testified that Dr. R's failure to perform a urinalysis during the two years of treatment was a departure from good medical care because that test is most effective for detecting kidney problems, a criterion for lupus. He also testified that because Ms. V already had three of the four criteria for lupus, Dr. R should have been closely monitoring her kidney function, and a urinalysis is far better than the creatinine testing that Dr. R was using. Dr. R's expert testified that it was not necessary for Dr. R to perform a urinalysis because Ms. V had not exhibited any symptoms of possible kidney damage prior to the swollen feet and ankles.

After deliberating for several hours, the jury returned a verdict of $200,000. However, the jury found that Ms. V was contributorily negligent and apportioned 40% of the responsibility for her injuries to Ms. V herself and the remaining 60% to Dr. R.

Legal backround

Contributory negligence is the legal term for when someone has contributed to his or her own injuries. In cases where contributory negligence exists, the jury will determine to what extent the plaintiff was responsible for his or her own injury. In some states, in cases where the plaintiff was responsible for more than a certain percentage of the injury, no damages will be awarded. In other states, the total damages will be reduced by the amount for which the plaintiff was responsible. In this case, Ms. V did not follow up with Dr. R after her endocrinologist told her to, and then she stopped taking one medication (although she told Dr. R of this) and decreased another medication (without telling him). By doing so, she contributed to her own kidney failure, and the jury recognized this by reducing the damages in this case.

Protecting yourself

There is a great deal of talk in the news about physicians ordering unnecessary tests to protect themselves from potential malpractice suits. This is an issue in terms of costs (some tests are quite expensive), and the effects on patients (some tests are invasive). A urinalysis however, is neither invasive nor costly. Dr. R was aware that Ms. V had three of the required four criteria for a diagnosis of lupus. He also was aware that kidney involvement was another one of the criteria for lupus, and therefore something to watch for. The easiest and best way to monitor for that would have been to perform a urinalysis on Ms. V – at least once a year. Had he done so, she could have been diagnosed, and therefore treated, earlier.

If you are aware that a patient has many, but not all, of the criteria necessary to diagnose a serious condition, you are obligated to monitor that patient to determine if any new symptoms develop. A urinalysis in this case would have been a relatively simple way to do so.

http://www.cortlandtforum.com/a-difficult-case-a-noncompliant-patient-with-a-battery-of-symptoms/article/172601/