Failure to Connect the Dots During Multiple Visits

A 38-year-old male first presented to a multi-site primary care practice with a primary complaint of hemorrhoids. The physician diagnosed a bleeding hemorrhoid and gave the patient educational material to follow (blood pressure was 138/94). Seven months later, the patient was seen by the same physician, as well as a nurse practitioner, with a chief complaint of earwax (BP 110/90).

He was next seen in the practice two years later, by a different physician, for a persistent cough (BP 132/100). The diagnosis was bronchitis, hypertension, and smoking dependency. He received prescriptions for antibiotics and cough medicine. In addition, the physician recommended smoking cessation and asked the patient to return in one month for a blood pressure check. The patient did not return for the check up.

Seven months after that visit, the patient returned with right ankle pain (BP 144/98). He was seen by a third physician, who diagnosed a sprained ankle and prescribed Ibuprofen and an air cast. The patient returned for a one-month follow up with one of the earlier physicians, with continued ankle pain and swelling (BP 134/92). He received Indocine for his ankle pain, as well as recommendations that he follow a low salt diet, exercise regularly, and return in 3-6 months to have his blood pressure rechecked.

He returned in two months with continued foot and ankle complaints. He was seen by an NP, who referred the patient to Orthopedics (BP 130/88). When seen by Orthopedics a week later, his X-rays were negative for a fracture. He was placed in a walking cast, which was removed three weeks later.

Nine months later, the patient was treated for hemorrhoids (no BP noted). During a subsequent appointment soon after, the patient has earwax removed by an NP (BP 122/88).

The patient returned again six months after that, and was seen by a fourth physician. who diagnosed bronchitis (BP 144/88). In less than a month, he was seen for hemorrhoids (BP 165/105, upon repeat 130/90). The patient was asked to follow up with his PCP.

Two days later, the patient was seen by an NP for a routine health maintenance exam and blood pressure follow up. He was noted to have no family history of hypertension, but a positive history for diabetes. Blood work was obtained, and the patient was educated about life style changes and advised to return in three weeks for blood pressure follow up. The patient did not keep that appointment.

Two months later, the patient was seen by an NP to follow up on hypertension and laboratories. The NP’s impression was hypertension, hypothyroidism, and hypercholesterolemia. She prescribed medication for hypothyroidism and discussed smoking cessation. The patient was asked to return in 6-8 weeks.

Two months after that, at age 43, the patient was found dead by his wife, after having an acute myocardial infarction.

Clinical Perspective

1. The patient was predominantly treated episodically by multiple providers within the same practice, and it was not clear who the primary care physician was.
   Appreciating the seriousness of a patient’s condition can be difficult at times, especially when the patient comes in only episodically with varying complaints. Patients like this need to have someone overseeing the bigger picture, pulling the pieces of the puzzle together. Ideally in the primary care setting, every patient has a primary care physician and a relationship is developed between the provider and the patient seeking care. PCPs also maintain a comprehensive medical record for the patient, in which pertinent medical information and plans of care are kept. This information is useful, not only to the PCP, but also to any other practitioner within the practice following up with the patient. Effective communication among teams of caregivers can make the difference between an optimal outcome and an adverse event. Updated problem lists can help covering clinicians understand the patient’s past and present medical conditions. Especially with patients who come to a practice often for episodic care, every physician caring for a patient should establish with other providers who will serve in a coordinating role. If no one is responsible for coordinating care, then it is left up to the patient, which is a failed solution.
   
   
2. Multiple providers failed to take an up- to-date medical and family history across multiple encounters, thus missing the opportunity to factor that history—which included cardiac disease, high cholesterol, and smoking—into his diagnoses and treatment.
   Family history often provides the first clues that a patient may be at high risk for developing certain conditions, and it must be updated periodically to incorporated new developments. This history is a key component to the providers' formulation of a clinical impression and working diagnosis. For example, a history of smoking, high cholesterol, and hypertension could lead to more timely intervention for heart disease.
   
   

Patient Perspective

1. For the first six years that this patient was seen by this practice, he never had a complete assessment (i.e., complete physical exam and patient/family history).
   After a bad clinical outcome, a patient’s family might look back at several visits over several years at the same practice, and ask if some basic things were done. They will look for reassurance that providers took adequate measures to identify risk factors and offer treatment to maximize the patient’s chances of survival. Episodic care that is exclusively reactive with no action to “connect the dots” may appear insufficient. Patients and their families want to know that everything reasonable was done to prevent the outcome, especially if multiple signs and symptoms could have signaled an underlying disease or vulnerability that is often treated effectively.
   
   

1. The patient consistently missed recommended follow up appointments.
   To encourage the patient to participate in the care process and take responsibility for his/her health care, the patient must be fully informed of the issues and the risks, benefits and alternatives to treatment. In the event a patient fails to follow up as recommended, documentation of the advice to the patient is crucial for both better care of the patient and to the defense of any potential claim. Such defense is further bolstered by the physician’s documented reminders and follow-up with patients who fail to keep appointments. Any outreach telephone calls or letters to the patient must be documented in the medical record. Practices are responsible for making a reasonable effort to contact patients who miss scheduled appointments or tests. The reasonableness of the effort depends on the clinical importance of the test or visit, the severity of the patient's medical condition, and the risk associated with the missed appointment. For patients at minimal risk, a single phone call or postcard following the missed appointment may suffice. For patients whose care requires ongoing monitoring or treatment, a more concerted effort (perhaps including certified mail) should be made to inform them about the specific risks of missing appointments. Attempts to obtain follow-up, as well as missed appointments, failure to follow care instructions, and any other examples of patient non-adherence should be documented.
   
   

Legal Defense Perspective

1. The jury agreed with the defense expert who cited guidelines from the Joint National Committee on Prevention that state a patient with this history and blood pressure readings should be initially monitored and educated about changes to diet and exercise.
   A claim is more defensible and may never be brought if the documentation supports the clinician’s decision-making process. A documented discussion with the patient about the nature of a diagnosis and the reasons not to immediately prescribe medication can establish later that a well-defined treatment plan had been formulated, based on specific guidelines, rather than allowing the possibility that an omission had occurred.