There will always be noncompliant patients. Physicians treating those patients need to foster a heightened sense of danger.
A patient nearing 40 years of age consulted with Dr. OB, an obstetrician who had delivered her previous five children. Ultrasound revealed an intrauterine single viable fetus with a gestation age of eight weeks and five days. Dr. OB asked the patient to return in two weeks, but she instead came back just over a month later, at which time the fetus was 13.5 weeks.
Though first trimester screening was still available by dates, Dr. OB instead planned a sonogram and second trimester blood work on the next visit, which was scheduled for three weeks hence. After the patient failed to show for a rescheduled visit, she finally returned to Dr. OB’s office after a period of almost six weeks. At 20 weeks of gestation, the fetus was at the last day for a second trimester screening. Instead of doing a screening, Dr. OB planned for a one-hour glucose test on the next visit scheduled for about a month later.
The patient failed to show for that appointment and instead showed up when the fetus was at 30 weeks. An ultrasound showed a viable baby boy with adequate amniotic fluid. The patient failed to return for her scheduled visit two weeks later.
Approximately five weeks after her last visit with Dr. OB, the patient was admitted for labor and delivery through the emergency department. Dr. OB was called when an examination showed positive fetal movement. Among the findings were a decrease in fetal movement and severe low amniotic fluid. Dr. OB arranged for the patient’s transfer to a regional facility, where she gave birth to a son with Apgars of 8 and 9 and complete imperforate anus. Genetic testing confirmed the child’s Down Syndrome.
The child’s parents pursued a “wrongful life” lawsuit, which resolved informally prior to arbitration.
A review of Dr. OB’s chart showed no signature by the mother on the California prenatal screening booklet, and Dr. OB testified in deposition that he did not do the first or second trimester screens because the ultrasounds showed the patient to be past the respective cutoffs.
Dr. OB’s judgment on whether to perform those tests stood in sharp relief to a patient whose repeated, critical no-shows should have put him on red alert. Instead, the chart revealed no consideration of a referral and no discussion with the patient on the importance of prenatal testing.
A patient’s noncompliance can be viewed as a challenge to a physician’s plan of care. In the face of such a challenge, a physician who responds by reasserting his or her active role in meeting medical objectives can help avoid injuries and exposure.
Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to gownby@CAPphysicians.com.