Toward a Coordinated Approach to Critical Situations

When the medical approach to a particular situation differs among healthcare providers within a practice, such conflict may surface later – in litigation.

A 50-year-old teacher visited the medical group of his family care physician because of chest pain and a cold. With his regular physician out of the office that afternoon, the gentleman was seen by a physician assistant. The PA noted that the patient’s cold symptoms and mid-sternum chest pain (like a “heavy weight”) developed the day before. A history showed no previous chest pain but high cholesterol and a prescription for Lipitor that the patient wasn’t taking. Though an EKG that day was read by the machine as borderline, the PA interpreted the test as essentially unchanged from three months earlier.

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The PA’s sparse EMR (the medical office has just recently shifted from paper records) did not document whether the patient was experiencing chest pain at the time of the visit. Blood pressure was 100/74; pulse was 68; and respirations were 16.

The PA diagnosed the patient with chest pain and ordered a check of cardiac enzymes with a troponin draw. Because the patient was adopted, the PA referred him to a cardiologist for risk assessment after ordering a chest X-ray. The PA also prescribed a prescription for hypercholesterolemia. After giving him “ER precautions,” the PA discharged the patient home.

That evening after dinner with his wife and child, the patient went to the bedroom to watch television. His wife later found him unresponsive and resuscitation efforts by an emergency team were unsuccessful.

The next morning, Dr. FP, the patient’s family care physician, reviewed and signed off on the PA’s chart entry as the “supervising provider.”

Early that afternoon, however, the lab called the office reporting critical values, including troponins at 4.5 (reference 0 to .04). The PA immediately called the patient’s cell phone and reached a brother-in-law, who reported the patient’s death the evening before from a heart attack. The coroner’s report listed cause of death as myocardial infarction with hypertensive and atherosclerotic cardiovascular disease.

The patient’s family sued, claiming that given the gentleman’s complaints, the PA should have sent him immediately to the emergency room.

In the ensuing litigation, attention focused on the PA’s failure to document whether the patient (whose anxiousness was noted) was experiencing active chest pain during the visit. In her deposition, the PA testified she had a specific recollection that the patient was not in distress during the visit but admitted she did not document the absence of cardiac symptoms. She said that had the patient told her or the appointment staff of active chest pain, she would have sent him to the ER immediately.

As for the troponin order, the PA testified that her rationale for the test was not in the context of an urgent or emergent situation, but rather to assist the cardiologist in evaluating the patient’s risk factors.

During his own deposition, Dr. FP was asked by the family’s attorney about his own practice of ordering cardiac enzymes. Dr. FP testified that he does not order such tests in an office setting, though he understood that the PA and at least one of his physician partners do. Dr. FP and the PA testified the medical office did not have an algorithm dictating how a physician assistant is to treat certain patients.

The case resolved informally.

Dr. FP’s deposition offers a somewhat rare example as to how different medical approaches within a single practice (in this case, ordering troponin for a referral versus at the hospital) can surface in litigation. While independent medical judgment must always be valued, medical practices may benefit from discussions on how to keep such differences to a minimum.   


Gordon Ownby is CAP’s General Counsel. Questions or comments related to “Case of the Month” should be directed to