Lawsuit for not checking labs

[Kaustikos]

Now I see pro cal ordered by everyone and anyone as the “bacteria barometer” versus using it as a way to deescalate antibiotics more quickly in sepsis .

On the consults for pneumonia I get, procal borderline high vanc zosyn becuase the patient was in a rehab center recently or something … unimpressive cxr - no sputum Cx or urine antigens ordered - when I talk to the patient the patients Tend to tell me sure I’ll give you sputum just give me a cup!

You're going to give me a stroke.

Next you'll tell me they order procal for patient with staph aureus bacteremia (which, I've seen).

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[VA Hopeful Dr]

Nothing against you if that's how you practice. I'm sure it can work.

I've seen a lot of patients get annoyed when they come in for one thing and have additional things added on. But again, it probably works for some.
I like annual visits because it also gives the patient an opportunity to buy into preventative care and it allocates time to do all those things. Discussing all pertinent screening with an overweight 55 year old male who has not had any recent check ups in years is tough to do when they come in with a rash, shoulder pain and low back pain.


Doing a CBC, CMP, lipid screening annually to every other year, A1C (unless they're skinny) +/- TSH every few years is how most primary care doctors practice in the community. There's nothing unreasonable about it, when it's literally what most do.

Sure, and if they don't want to do it then I offer an appointment in a few weeks to address all of that.

 

[NewYorkDoctors]

Dunno why many primary teams in the hospital don’t ever order a sputum culture for patients with lower respiratory tract infection . But blood cultures ? Oh yes because qsofa or SIRS met just get blood culture . Baby put peg in hole . Also I get that not all patients have sputum on demand (without using hypertonic saline - which the hospitals respiratory department has … ) but common at least put in the order and write it in H&P so I see at least some minimal effort was used

At least it’s easy to get a tracheal aspirate once I see the patient intubated for respiratory failure

 

[Kaustikos]

Dunno why many primary teams in the hospital don’t ever order a sputum culture for patients with lower respiratory tract infection . But blood cultures ? Oh yes because qsofa or SIRS met just get blood culture . Baby put peg in hole . Also I get that not all patients have sputum on demand (without using hypertonic saline - which the hospitals respiratory department has … ) but common at least put in the order and write it in H&P so I see at least some minimal effort was used

At least it’s easy to get a tracheal aspirate once I see the patient intubated for respiratory failure

BUT they got the UA!!!!

 

[Renal_Prometheus]

To be fair, I do not expect a non-nephrologist to know that meslamine can cause interstitial nephritis. It’s really out of their scope of knowledge.

 

[Kaustikos]

To be fair, I do not expect a non-nephrologist to know that meslamine can cause interstitial nephritis. It’s really out of their scope of knowledge.

I may be making an assumption, but given that our field has to know every side effect/adverse reaction to antibiotics/fungals/virals, I'd assume a Gastroenterologist would know the adverse effects of a first line therapy for a GI disease.

 

[rokshana]

Nothing against you if that's how you practice. I'm sure it can work.

I've seen a lot of patients get annoyed when they come in for one thing and have additional things added on. But again, it probably works for some.
I like annual visits because it also gives the patient an opportunity to buy into preventative care and it allocates time to do all those things. Discussing all pertinent screening with an overweight 55 year old male who has not had any recent check ups in years is tough to do when they come in with a rash, shoulder pain and low back pain.


Doing a CBC, CMP, lipid screening annually to every other year, A1C (unless they're skinny) +/- TSH every few years is how most primary care doctors practice in the community. There's nothing unreasonable about it, when it's literally what most do.

uh...you know diabetes, type 2 can occur in "skinny" pts, right? and exactly how do you determine ne a person is "skinny"? BMI? are you taking into account that Asian pts are considered to be at greater risk for DM with BMI 23.

there is no reason to "screen" for TSH...or do thyroid antibodies every so often...its a once in a lifetime test...you are positive, its positive...and please don't freak out the hypothyroid pt that they have positive antibodies!...Hashimoto's is the most common reason and if they are already on levothyroxine, its not gonna change there management. and if you do...please don't refer to Endocrine...you will not like what we have to say...

 

[MedicineZ0Z]

uh...you know diabetes, type 2 can occur in "skinny" pts, right? and exactly how do you determine ne a person is "skinny"? BMI? are you taking into account that Asian pts are considered to be at greater risk for DM with BMI 23.

there is no reason to "screen" for TSH...or do thyroid antibodies every so often...its a once in a lifetime test...you are positive, its positive...and please don't freak out the hypothyroid pt that they have positive antibodies!...Hashimoto's is the most common reason and if they are already on levothyroxine, its not gonna change there management. and if you do...please don't refer to Endocrine...you will not like what we have to say...

Yes BMI, meaning I'm not screening a 25 year old active person with a BMI of 21. But do I screen 20-30 something year olds who are not obese and perhaps just marginally overweight? Absolutely. Not to mention that it helps motivate someone to tell them they are pre diabetic and need to lose weight vs just "counseling" which almost never achieves anything when it isn't tied to an objective finding.

I do screen for TSH once and then repeat every few years maybe. I do thyroid antibodies if there's a major indication only, why would I repeat?
And the only patients I refer to endo are ones with truly rare zebras after diagnosis or type 1s. I follow my own Graves, high dose insulin type 2s, adrenal insuffiency etc.

 

[MedicineZ0Z]

Sure, and if they don't want to do it then I offer an appointment in a few weeks to address all of that.

So you schedule them for some form of health maintenance visit? Which is... essentially a physical.

Basically doing targeted physicals for those who happen to come in for something else.

 

[VA Hopeful Dr]

So you schedule them for some form of health maintenance visit? Which is... essentially a physical.

Basically doing targeted physicals for those who happen to come in for something else.

Exactly! I bill it as a physical (because there is no other way yet) but I discuss it with the patient as a visit for "targeted screenings" since my actual physical exam is perfunctory at best.

 

[NewYorkDoctors]

I may be making an assumption, but given that our field has to know every side effect/adverse reaction to antibiotics/fungals/virals, I'd assume a Gastroenterologist would know the adverse effects of a first line therapy for a GI disease.

Some GIs in the community literally only want to scope . They hire mid levels to do the consults for HBV IBS fatty liver etc … if it’s a complex cirrhosis or IBD case , I’ve seen them do the scopes then refer to academic GI for the other management (ie talking and non scoping for dollars )

 

[MedicineZ0Z]

Exactly! I bill it as a physical (because there is no other way yet) but I discuss it with the patient as a visit for "targeted screenings" since my actual physical exam is perfunctory at best.

But doesn't that mean only patients who happen to come in for something acute end up getting screened? Whereas patients who are at home with a BMI of 40 don't come in since nothing is bothering them?

 

[VA Hopeful Dr]

But doesn't that mean only patients who happen to come in for something acute end up getting screened? Whereas patients who are at home with a BMI of 40 don't come in since nothing is bothering them?

You do realize that people can make appointments for themselves whenever they want to, right?

 

[MedicineZ0Z]

You do realize that people can make appointments for themselves whenever they want to, right?

So in other words you offer annual physicals lol.

 

[VA Hopeful Dr]

So in other words you offer annual physicals lol.

Exactly! I bill it as a physical (because there is no other way yet) but I discuss it with the patient as a visit for "targeted screenings" since my actual physical exam is perfunctory at best.

 

[bronx43]

Some GIs in the community literally only want to scope . They hire mid levels to do the consults for HBV IBS fatty liver etc … if it’s a complex cirrhosis or IBD case , I’ve seen them do the scopes then refer to academic GI for the other management (ie talking and non scoping for dollars )

Even at academic centers the GIs just scope. The only difference is that the NPs in “academia” are just seeing complex disease as opposed to the NPs in the community. I remember sending a patient with mesenteric lymphadenitis, elevated liver enzymes and positive autoimmune serologies to my friendly local academic GI division… only to get back a NP note addressing GERD.

Honestly, GI at this point is a joke.

 

[NewYorkDoctors]

Did the GI note mention discussion about more than just PPI use ? Diet changes , waiting 4/5 hours after a meal before laying down, lay on left side , get a bed wedge vs automated bed ?

 

[chessknt]

Even at academic centers the GIs just scope. The only difference is that the NPs in “academia” are just seeing complex disease as opposed to the NPs in the community. I remember sending a patient with mesenteric lymphadenitis, elevated liver enzymes and positive autoimmune serologies to my friendly local academic GI division… only to get back a NP note addressing GERD.

Honestly, GI at this point is a joke.

Yep. Inpatient is even worse because they tend not to have the NP there and will blow off anything that isnt a scope. Had a young woman come in with LFTs in the thousands that I thought warranted a liver workup. When it became apparent I wasn't asking for an ERCP I got a bunch of nonsense over the phone how they couldnt help and send her a transplant center etc etc that took longer than writing a ****ing note did.

 

[bronx43]

Did the GI note mention discussion about more than just PPI use ? Diet changes , waiting 4/5 hours after a meal before laying down, lay on left side , get a bed wedge vs automated bed ?

Lol pretty sure that was all in their dotphrase.

 

[NewYorkDoctors]

Lol pretty sure that was all in their dotphrase.

Yep pretty much . For the bronchiectasis NTM patients I often spend much time saying these things out loud and reiterating it many times . The patients often say but why didn’t the GI tell me these things ? I could say the GI don’t believe in non acid reflux and they need esophageal manometry and pH probe done (only at academic center - doesn’t pay well enough in PP) . I usually end up saying well the NTM has to have come from somewhere . But now I’ll say it was in the dot phrase

 

[MedicineZ0Z]

Even at academic centers the GIs just scope. The only difference is that the NPs in “academia” are just seeing complex disease as opposed to the NPs in the community. I remember sending a patient with mesenteric lymphadenitis, elevated liver enzymes and positive autoimmune serologies to my friendly local academic GI division… only to get back a NP note addressing GERD.

Honestly, GI at this point is a joke.

And for this reason I pretty much don't do GI referrals unless it's directly to hepatology for biopsy proven disease for definitive management or for a procedure.

 

[Siggy]

Dunno why many primary teams in the hospital don’t ever order a sputum culture for patients with lower respiratory tract infection . But blood cultures ? Oh yes because qsofa or SIRS met just get blood culture . Baby put peg in hole . Also I get that not all patients have sputum on demand (without using hypertonic saline - which the hospitals respiratory department has … ) but common at least put in the order and write it in H&P so I see at least some minimal effort was used

At least it’s easy to get a tracheal aspirate once I see the patient intubated for respiratory failure

Sputum cultures are literally the only correct answer for most PNAs. The one advantage with ICU is that being in the ICU is essentially an indication for the sputum culture... and the blood cultures and serology tests.

At least one of my hospitals includes flu A/B and RSV in their COVID tests. Otherwise getting a flu swab and respiratory viral panel inpatient takes an act of god (insert nursing whine that patient already had a swab done).

 

[Siggy]

Yep. Inpatient is even worse because they tend not to have the NP there and will blow off anything that isnt a scope. Had a young woman come in with LFTs in the thousands that I thought warranted a liver workup. When it became apparent I wasn't asking for an ERCP I got a bunch of nonsense over the phone how they couldnt help and send her a transplant center etc etc that took longer than writing a ****ing note did.

In fellowship we had an acute liver injury patient on about 5 meds. GI was stumped... I googled "med" and "liver injury" until the azathioprine hit on liver tox. Patient got transferred because GI was stumped, but not before IR did a biopsy... which showed cholestasis.

 

[chessknt]

In fellowship we had an acute liver injury patient on about 5 meds. GI was stumped... I googled "med" and "liver injury" until the azathioprine hit on liver tox. Patient got transferred because GI was stumped, but not before IR did a biopsy... which showed cholestasis.

Did they scope it for more information then sign off?

 

[MedicineZ0Z]

@VA Hopeful Dr
That's my point though. It's all semantics, but basically you don't actively pursue preventative visits and just offer it to those who want it.

 

[VA Hopeful Dr]

@VA Hopeful Dr
That's my point though. It's all semantics, but basically you don't actively pursue preventative visits and just offer it to those who want it.

Correct. But I still make sure their preventative screenings are up to date which is the important part.

 

[TransformerInWestVirginia]

But you didnt protect yourself from lawsuits! Better get ready for all the lawsuits coming your way because you didn't detect the start of their CKD 3 years ago from medicine someone else was prescribing for a condition you weren't managing. I know every person who comes in to clinic with a cough, shortness of breath, or well **** it lungs is getting a CT chest to make sure I dont miss cancer so now I can never be sued.

youre...comparing apples to oranges. if a patient's shortness of breath is the only complaint, nobody is going to sue you for "missing" a CT diagnosed condition. If there was fifty other red flags, then yea. But thats why we went to medical school and spend all this training. The ED mentality should stay in the ED, not every tachycardia needs a CTA, not every abdominal pain needs a troponin.

people usually get sued when and only when there is a clear error. Not checking labs on this patient is an error. period. Do i think PMD should have been sued? No. For the same reasons that people above have mentioned (once you refer, you trust that everything to do with that specific complaint will be followed). To be frank, the PMD getting sued is bull. I am surprised he settled. I would have fought tooth and nail.



to OP: thank you for getting me hooked on this website. There goes the rest of my free time.

 

[PikminOC]

So from what I read, the GI/PCP were found negligent for their failure "to inform" the patient of the risks of the medication? ie they never mentioned (or likely never documented mentioning) the necessity of close f/u with regular labs? It's a bit of stretch, I feel for the PCP and GI. I'm sure they counseled the patient, maybe they just didn't document having done so.

This is why I check labs on all of my patients, q 12 months at the least, even if it's not clearly indicated. "That's not cost conscious care, I'm not choosing wisely???" IDGAF.

Yes cya medicine costs a lot. No one mentions this with medical reform.

 

[anonperson]

youre...comparing apples to oranges. if a patient's shortness of breath is the only complaint, nobody is going to sue you for "missing" a CT diagnosed condition. If there was fifty other red flags, then yea. But thats why we went to medical school and spend all this training. The ED mentality should stay in the ED, not every tachycardia needs a CTA, not every abdominal pain needs a troponin.

people usually get sued when and only when there is a clear error. Not checking labs on this patient is an error. period. Do i think PMD should have been sued? No. For the same reasons that people above have mentioned (once you refer, you trust that everything to do with that specific complaint will be followed). To be frank, the PMD getting sued is bull. I am surprised he settled. I would have fought tooth and nail.



to OP: thank you for getting me hooked on this website. There goes the rest of my free time.

Physicians get sued when there is a bad outcome. The presence of a "mistake" or "error" is irrelevant to the trial lawyer and the patient.

If there is any type of bad outcome, even if you did everything according to the standard of care, don't be surprised if an attempt at a lawsuit occurs.

The system is setup this way. Trial lawyers feast on it. Dirtbag physicians offer "expert" opinions for them acting like bottom feeders. It's a messed up system.

 

[DrMetal]

Yes cya medicine costs a lot. No one mentions this with medical reform.

No one is breaking the bank of medicine, by checking a CBC/CMP/Lipids/A1C, once every 1-2 years, on a 74-yo taking 8 medications (1/2 of which he's not compliant with). Reasonable labs and rads, for reasonable reasons. Get 'em, protect yourself. Eff the guidelines that tell you not to. (Everybody loves to preach 'guidelines' until it's their name on the chart).

 

[PikminOC]

No one is breaking the bank of medicine, by checking a CBC/CMP/Lipids/A1C, once every 1-2 years, on a 74-yo taking 8 medications (1/2 of which he's not compliant with). Reasonable labs and rads, for reasonable reasons. Get 'em, protect yourself. Eff the guidelines that tell you not to. (Everybody loves to preach 'guidelines' until it's their name on the chart).

It's not just labs. And it's alot of people. And if course you have to practice cya med in the us.

 

[Kaustikos]

It's not just labs. And it's alot of people. And if course you have to practice cya med in the us.

HA! This is only funny because we had a patient presenting which we were consulted for and she had labs 2 years ago which no one followed up on and directly related to why she's having all these issues. I told the primary team but nothing happened again. ¯\_(ツ)_/¯

 

[NonNocere]

Mesalamine Kidney Failure

Case #95

expertwitness.substack.com

28 year old with UC given mesalamine for 8 years by GI doc which the drug caused CKD IV and eventually he got a renal transplant.

Lawsuit filed against GI and PCP for not checking labs in the 8 year period.

Here is the thing: GI was controlling the management of UC with mesalamine. They never checked labs in the interim. The PCP also was not visited for 5 years prior to CKD discovery. In fact CKD was diagnosed by the PCP when care was re-established in the 8th year of mesalamine treatment and routine labs were checked!!

How is it the PCP is on the hook for diagnosing/“saving the patient” and when it’s all GI’s fault?

In law, in my understanding, lawyers must add all potential defendants at the beginning. The lawyer probably doesn't have medical training so I think you can understand. That is one of the reasons medical liability ("malpractice") insurance is so important.