Was This Primary Care Provider Too Rushed?

The following case abstract is from closed malpractice claims in the Harvard medical system. Some details have been changed to mask identities.

Commentator: Carla Ford, MD

Transcript

A 50-year-old male patient was seen in his primary care provider’s office by a nurse practitioner. He presented with complaints of dizziness, left arm weakness, and fatigue. He had a history of poorly controlled diabetes, hypertension, hyperlipidemia and a cervical disc herniation.

The nurse practitioner did a neuro exam that did not include tests for cerebellar function or sensation and merely described strength as “5/5 bilaterally.” She ordered cervical spine x-rays. Blood pressure was normal and pulse elevated at 102. An EKG showed no acute changes, and the x-rays showed degenerative changes of the cervical spine. Dizziness was reproduced using Epley maneuver. The NP suspected vertigo was causing the dizziness, and ascribed the arm weakness to disk disease. The patient was told to go to the ED if symptoms worsened. There was no discussion of stroke as a possible cause of the symptoms.

The next day he developed a left-sided facial droop and weakness at work so he went to the ED. A CT scan showed a large infarct of the right frontal parietal and temporal lobes. The patient received IV TPA with some improvement. He has residual brain damage, weakness, facial droop, slurred speech and visual deficit. He sued the nurse practitioner for negligent failure to consider stroke in her misdiagnosis, and the case was settled for more than $1 million.

To discuss the risk management and patient safety aspects of this case, we are joined now by Dr. Carla Ford. Dr. Ford is a consulting physician for CRICO, the patient safety and malpractice insurance company for the Harvard medical system.

Carla, thank you for joining us:

A) Tom, thanks for having me.

Q) When we look at a diagnosis that’s missed that seems to not be that hard to make or to consider, is this a lack of experience or the kind of thing that could happen to anybody?

A) This is the kind of thing that can happen to anybody, and I think that this is the type of thing that may reflect sort of the rushed nature of care these days. The crux of this case is that a detailed history and detailed physical exam were not performed and so a broad differential was not considered. And it was easy enough to sort of jump to what appeared to be the diagnosis, and that really can happen to anyone. A single visit is the issue of negligence in this case, and this is a patient who presented with dizziness and left arm weakness in the context of having multiple risk factors for vascular disease, including hypertension, diabetes, and hyperlipidemia. So if I say it that way, it sounds like a stroke, but the problem is patients don’t say it that way. So it’s important to slow down and really tease out the nuances of when the symptoms started, did they happen at the same time? What was the severity? What was the time course? And I think in this case as soon as the patient said ‘I have dizziness when I move,’ the provider sort of jumped to the common diagnosis of benign positional vertigo without really considering how all the symptoms might fit together.

Q) So it’s looking at symptoms being together. If it happens at the same time, they are probably connected. Are there are some rules of thumb here?

A) Yes, I think that when symptoms occur at the same time, chances are overwhelming that they are related. And so to ascribe the dizziness to one problem—the benign positional vertigo—happening at the same time that arm weakness is related to cervical disc disease, is really outside the bounds of what one would normally consider. It is much more likely that those two symptoms of dizziness and arm weakness are related, and the way that they would be related is through cerebrovascular disease. You know, Tom, one of the challenges for providers in the office is to sort of pick out that person who’s having a really serious problem. Everyone thinks about, if you’re in the ER, you just don’t want to send someone home with a heart attack. It’s even harder for primary physicians who are out in the office and may have 20 or 25 or 30 patients they’re seeing every day to find the person who is having a really serious problem with what appear to be relatively benign complaints.

Q) That really is the crux of what clinicians are up against today in a busy primary care practice: being able to take the time, be able to be detailed in your note taking. This is something that’s really challenging for everybody, isn’t it?

A) When you look at the note written by this provider, it’s almost as if there’s a scattered type of thinking, which again leads me to think that certainly in my time practicing that you’re rushed. You have an idea of where you want to get to, what you think this patient has, and so there was sort of a scattered documentation. For instance, with regard to the dizziness, the provide must have been thinking somewhat about vascular disease because she ordered an EKG and she ordered orthostatic blood pressures to look for orthostatic hypotension but then did not consider cerebrovascular disease. In this case, I think the most telling part of the history was the left arm weakness because the patient said that they were not able to pick up things, and that really is more than just, you know, I feel a little less strong on that side. It’s a pretty significant symptom. So I think it is the challenge of primary care to pick out patients who are having really serious problems and to think of those things first.

Q) But actually it takes a lot of discipline to stop when you think you know what it is and develop a broader differential, is that true?

A) Well, it’s a very easy trap to fall into. The patient says something that sort of triggers something in your mind. Oh, I think it’s this and then, you know, that’s why experienced clinicians know that they need to sort of stop, take a more detailed history and do a more detailed physical exam and had she done that and put it together with the historical points of all the risk factors for cardiovascular and vascular disease, I think she would have arrived at the diagnosis.

Q) In the end, the courts don’t fault you for being wrong, right? They are going to fault you for something else, but being wrong is not negligence.

A) That’s right, Tom. I mean, medicine is complicated. The human body is complicated, and it is not negligence to be wrong at the end of the day. What is negligent is to not follow the process of doing a history, doing a physical exam, generating a differential diagnosis, you know, sort of explaining or justifying your top disease in the differential and then doing proper treatment. What the standard of care requires is what an average qualified provider in the same position would have done. The problem in this case is that the process wasn’t followed to the degree of detail that an average qualified provider would do at that time.

Thank you. Dr. Carla Ford is a consulting physician for CRICO, the patient safety and malpractice insurance company for the Harvard Medical System. I’m Tom Augello.