Following Up on First Impressions

Remember the exam-taking advice telling you to go with your first impression if no other answer seems to fit? Fast forward to your clinical practice today and that advice may still apply: At the least, be sure to follow through on your original suspicions when assessing a patient’s complaints. If you don’t, you’ve only helped a plaintiff attorney write his or her trial argument.

A 65-year-old gentleman presented to Dr. FM, a family medicine physician, with a two-week history of abdominal pain, loose stools, and diarrhea. The patient had recently been in Mexico and reported that his abdominal pain began after eating at a stateside seafood restaurant 11 days earlier. According to the patient, he felt the pain after every meal.

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Dr. FM’s physical exam noted the patient’s abdomen as soft with diffuse tenderness, no masses, and no rebounding or significant guarding. Dr. FM’s assessment was “subacute abdominal pain, etiology uncertain” and questioned possible food poisoning. Dr. FM ordered an abdominal ultrasound and lab work. The patient was advised to call if the pain worsened or if he is unable to hold down food or liquids.

The patient had his ultrasound and lab work performed the next day. The US report noted “mild hepatomegaly,” but also concluded with a finding of “minimal free fluid in the right lower quadrant with possible thickened bowel in this area. CT correlation could be helpful.” The interpreting physician signed and released the report on the day of the procedure at 5:43 p.m.

The report on the lab samples collected that same day showed an elevated white blood count of 16.9 and an elevated glucose of 260. There was some evidence, however, that Dr. FM did not receive those results until they were sent to him by fax more than a week after the patient’s visit.

Though the patient missed an appointment scheduled for five days following the original visit, no one at Dr. FM’s staff attempted to contact the patient to inquire of his condition.

Three days after that, the patient was found dead in his apartment. An autopsy noted the cause of death as “peritonitis due to ruptured bowel.” A dispute asserted against Dr. FM by the gentleman’s survivors was resolved prior to the initiation of an actual lawsuit.

This column has highlighted on several occasions the litigation risk when a physician fails to follow through on his or her first instincts when assessing a patient. The risk management lesson in these cases is not, of course, that a physician cannot change his or her approach to treatment. Rather, the take-away is that when changing course, the record needs to show diligence in exploring the initial suspicion – especially in those cases where the first instinct turned out to be the correct one.

Here, the record showed that Dr. FM, by ordering the ultrasound, had decided that he would explore beyond the possibility of simple food poisoning. But though the ultrasound findings were not particularly alarming, Dr. FM’s choice to not timely contact the patient with the results or follow up with a CT scan if the patient was still ill, certainly would be exploited at trial. And by waiting for a week for lab results — which did include significant WBC and glucose values — Dr. FM would be exposed to a plaintiff attorney’s argument that he did not adequately follow up on his initial plan.

Again, this is not about being locked into any particular treatment plan. It is about diligently pursuing each prong of a plan to confirm an earlier suspicion or to defend a change in course.   

Gordon Ownby is CAP’s General Counsel, and this month marks 20 years of his “Case of the Month” column. We thank the CAP members who have made “Case of the Month” a regular reading habit. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.