Needle in a haystack indeed. Apparently 32 physicians and specialists in rheumatology, gastroenterology, cardiology, radiology, surgery, neurology, internal medicine and dermatology weren’t enough to prevent this malpractice suit.

Once in trial, a paper written by a medical student brought down the defense – which missed a case of a rare parasite.

The defense responds with the “jury is stupid” comment:

Baylor College of Medicine physicians provided excellent care for the patient, who arrived critically ill with numerous life-threatening conditions. Though we do not agree with the decision, we recognize the challenges faced by the jury in understanding the complicated medical testimony presented in this case.”

(via a reader tip)

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  • Michael Rack, MD

    “Upon autopsy, pathologists found her intestines, liver and lungs were infested with Strongyloides stercoralis, a tiny parasitic worm”
    The true lesson of this case is not to perform an autopsy, as an unexpected finding could lead to a malpractice suit.

  • Anonymous

    Out of that list of 32 specialists, why no infectious disease specialist? Given the rates of foreign travel and immigration, parasites once rare in the US are becoming more common, yet the medical profession seems not to have adjusted to this aspect of current life.

  • SarahW

    Not to mention one of the 32 recommended TWICE that she be seen by an infection disease specialist. And none of the specialists checked/ordered a stool sample. That’s what the case turned on, apparently.

    And I haven’t checked the order of authorship, but pathologists and radiologists authored the paper as well. The student isn’t the sole authorm. Is the student even the primary author? Students names appear on papers all the time, at the end of the list…. I’d appreciate if you’d clarify.

  • Anonymous

    As a general internist, can I make a somewhat snarky remark? I suspect what happened is that the only one of the 32 specialists who felt sincerely responsible for the patient was the internist. (cringe at screams of outrage). However, that internist and most others do not have the depth of knowledge to suspect that disorder. In my limited experience, most specialists mentally sign off when they leave the bedside, gleefully giving the responsibility for the “rest of it” to the dumb-dumb internist. The fault in this case lies with the pulmonologist who should have broadened his or her differential on a young woman from a foreign country on high dose steroids.
    b

  • Elliott

    Defensive medicine sure prevented THAT lawsuit. Well, I guess it couldn’t prevent the lawsuit, but it sure provided a bulletproof defense. Well, defensive medicine didn’t prevent the lawsuit, didn’t prevent a jury award, but that’s just because the jury was stupid.

    How about advocating and practicing intelligent medicine for a change?

  • Anonymous

    Rather interesting is that the plaintiffs in the case aren’t the children of the deceased woman, but the Texas Dept. of Family and Protective Services, who have custody of the children.

  • ismd

    Elliott, nowhere in the newspaper article can anything be construed that defensive medicine was practiced. As for 32 specialists, they very well could have been multiple members of the same specialty group. If anything, no ID consult was ever obtained. So, there’s just not enough info to support your ridiculous statement.

    How about making some intelligent comments next time?

  • Anonymous

    The true lesson of this case?

    As a physician, especially a specialist you have to keep in mind to do whatever you can to keep your name off a chart. Why did 32 physicians get thrown under the bus on this one? Academics seem to be more clueless when it comes to fighting the enemy, the lawyers. In a community hospital you’d never find 32 physicians stupid enough to volunteer to put their name on the chart. I’m actually starting to see physicians beg me not to have to write a note on high risk patients. Has anyone else experienced this?

  • Anonymous

    Yes, I was consulted by the gyne once, regarding a 15 years old pregnant girl, positive for cocaine, who weighed 100 lb and had hyperemesis gravidarum and uncontrolled diabetes. Since I am just an internist, I excused myself after reading the chart, refused the consult and called the endocrinologist.
    If she would have delivered a 2 lb, mentally retarded baby, I would have been part of the “negligent” crowd.

  • Anonymous

    1. Infectious disease consult should have been called. Any patient that has pneyumonia in a hospital should have an id consult. There is no downside to calling consults. When I have a patient admitted to the hosiptal I just call every consult possible…the specialist and I all get paid…and my ass is covered by doing so. The specialists are ususally happy that you did so also.

    2. I wouldn’t say that specialists sign off the case mentally…usually it is the internist that signs off the case, and I am one! I just call a whole bunch of consults, neurology, cardiology, pulmonary, and yes, ID, and let them handle it, and when I come by the hospital I just write…nl S1S2 RRR lungs – clear b/l, con’t curent management. Appreciate cardiology consult, appreciate blah, blah, blah….
    The specialists spend all their time in the hospital so they can monitor and figure out what is going on, I don’t have time to figure it out while seeing sore throat, viral bronchitis, prescribing Zpak all day as a doc-in-a-box.

    3. radiologists don’t see patients.

    4.Whenever a consultant writes to do something in the chart (e.g. id should be consulted, order ana, anca, esr, xray, mri, blah blah) do it!

    5. These people literally hit the lottery when they came to the USA…they wouldn’t have even known their mother had lupus if they were in Honduras…she probably would have died of renal failure before now…

    PRACTICE DEFENSE!

  • Dan R.

    So here’s my question…

    Which of the 32 physicians committed malpractice? Apparently all of them.

    But 32 physicians at an academic center (Baylor) almost by definition meet the requirements for community standard of treatment…

  • Anonymous

    “How about advocating and practicing intelligent medicine for a change?”

    I do agree an ID consult may have been helpful (the operative word is “may”). I also would have thought the alarm bells would have been going off in the rheumatologist since they see these pt’s often and know about the immunosuppression issues. That stated Elliot, unlike you I have taken care of many immunosuppressed rheumatogic pt’s with concern of possible opportunistic infections. This isn’t “cookbook medicine”. These are ususally very complicated confusing patients (hence 32 c/s). It is easy to play monday morning quarterback when you have no clue what you are talking about. Come talk to me after you have taken care of a few of these patients pal. Then you will have some idea what I am talking about. Otherwise you are just another clueless lawyer pontificating away.

  • Anonymous

    Dear Anon 8:51p

    As a doctor, I would be very embarassed to write something like that in public. You are saying that with your sickest patients, you spend even less time and thought than with your viral URI patients you give a potent anti-bacterial to. Did I just step into bizarro world? Might I recommend your relinquish the care of your inpatients to a hospitalist? Am I wrong here?
    b

  • Anonymous

    As a doctor, I would be very embarassed to write something like that in public.

    I am not the above poster.

    Where the hell do you practice that you have unlimited time to take care of these inpatients and run an outpatient practice. Most of the Internists where I practice round on their inpatients at like 7 am and then leave the hospital for the day. They never come back. You need to realize not eveyone practices in your utopia.

  • Anonymous

    These people literally hit the lottery when they came to the USA…they wouldn’t have even known their mother had lupus if they were in Honduras…
    I think you missed that it wasn’t the children who were suing, but the Texas Dept. of Family and Protective Services.

    Not being a doctor I don’t know enough to comment on the particular case, I just don’t think you should blame the innocent.

  • Anonymous

    I’m sure when the Avian flu hits the US, these 32 docs will go out of their way to come to work….along with the rest of us……NOT!!

  • RDL2001

    The med student was the lead author- the article is free and can be found here:
    http://www.jvir.org/cgi/reprint/13/6/635

    Aside from the tangential rants I feel that this case is of interest in terms of the verdict. The case clearly has 3 of 4 requirements to proceed but the key element is questionable: did her physicians deviate from the standard of care? Practicing medicine in retrospect is surprisingly easy- writing a post mortum paper based upon autopsy findings is even easier still.
    Of note is the reported high mortality rate even with treatment (see article) and that everyone assumes an ID consult would have saved her. Considering what appears to have been fairly significant GI bleeding it is questionable if the dx could or would have been made via a stool examination. There would probably be a greater diagnostic yield from bronchoscopy.
    Reading the case report I can only sympathize with her treating doctors in that the constellation of symptoms and the progression of events does appear to be consistent with lupus. I think a similar case was actually used on the TV series ER (dx of asthma though). I feel that this case is illustrative more to the fact that lay person juries expect a level of accuracy (perfection) that clinical medicine cannot provide rather than true malpractice.

  • gasman

    So which is the more altruistic group, the physicians, or the lawyers.

    Would lawyers ever consider publishing a description of their unfavorable outcomes in a peer reviewed and publicaly accesible journal? I think not.

    Physicians discuss poor outcomes because it is hoped that others will learn vicariously rather than have to reproduce the same steps that proceeded the patient’s demise.

    I have moderated problem based learning sessions at national meetings where the underlying message was ‘this was a poor outcome, this was how my actions were part of it, this is how the greater health care system was a part of it, this is what we learned and have changed; you can learn this lession without a patient having a poor outcome’ .

    Why would I subjet myself to this potential exposure but for the greater good. Show me the legal equivalent of case reports and problem based learning sessions. Somehow I don’t think the lawyers are as forthcomming as the physicians.

  • Anonymous

    I wouldn’t call the above discussion “tangential rants”…you can discuss what motivated the jury all you want (it’s academic)…we are trying to figure out how to protect ourselves from this in the future…

  • Anonymous

    The Med student happens to be the victim of the cliche “Shit flows down!”

  • Anonymous

    Unfortunately, the lesson is : don’t ask for an autopsy if a complicated patient dies. I say unfortunately, because we could learn from our mistakes, we could become better doctors by doing more autopsies.
    I wonder how the whole “say I’m sorry” thing will play out, I just don’t trust the system anymore.
    Yes, there are difficult cases out there and sometimes the best physicians can’t make the right diagnosis. Punishing them for that will only steer away physicians from difficult cases.

  • Anonymous

    “Would lawyers ever consider publishing a description of their unfavorable outcomes in a peer reviewed and publicaly accesible journal? I think not.”

    We already do. It’s called the Court of Appeals and Supreme Court decisions. One lawyer (or more) loses in each of them every day.

    Every bar magazine, or any group of lawyers, be it ATLA or the ABA Real Estate Section, has a periodical with cautionary tales. Many of them can be found in public libraries, and are chock full of cautionary tales on everything from statute of limitations issues to client relations. You can subscribe to any of them you want.

    I’ve never been to a continuing education course where at least a part of it was dedicated to learning from other lawyer’s mistakes. Like your profession, ours is constantly evolving, and new potential problems crop up every day. It’s the “practice” of law and medicine for a reason.

    Even our malpractice reprimands, suspensions, etc are usually listed in the bar magazines, with a short explanation of the reasoning, and if you want more info, they’ll give it to you. Unless of course a confidential settlement (physicians use those too) was had prior to a complaint being filed with the bar.

    If the President of the United States’ suspension is public record, and one can read the opinion of the Ark. Committee on Professional Conduct, why do you think the rest of ours wouldn’t be?

    CJD

  • Anonymous

    If I were one of the now infamous “32 physicians” I would stalk that med student during his/her entire career including internship/residency and write up every case where he screws up and submit them to JAMA, Annals of Internal Medicine, NEJM, Cell, whatever journal will print that crap…

  • Anonymous

    Don’t hate the player….hate the game…and the game is evil in this country…till we get the lawyers.

  • Anonymous

    “Even our malpractice reprimands, suspensions, etc are usually listed in the bar magazines, with a short explanation of the reasoning…”

    Interesting CJD as I have pointed out before my state’s medical board website is pretty open. You can look up a doc, where they went to school, residency, number of malpractice cases, open cases, and board actions (as it should be). In fact on the board action’s there is a PDF file (open to the public) where you can see exactly what happened and the action/saction. Now le’s go to my state’s bar website. By searching the lawyer you can get where they went to school and their area of interest. No comment’s on malpractice suits or bar action’s. If you dig around enough on the website you can find action’s (by the year) but no explaination as to what happened or a PDF file. You tell me which system is more open?

  • Anonymous

    do lawyers get sued for malpractice? That sounds like one of my wet dreams…anyone know the statistics on that? i thought it was rare…so posting it on a web site wouldn’t mean much.

  • Anonymous

    “Now le’s go to my state’s bar website. By searching the lawyer you can get where they went to school and their area of interest. No comment’s on malpractice suits or bar action’s. If you dig around enough on the website you can find action’s (by the year) but no explaination as to what happened or a PDF file. You tell me which system is more open?”

    What state are you in?

    Have you tried requesting the information? Or are you saying simply because it’s not on the Internet then the lawyers are hiding something?

    CJD

  • Anonymous

    I am talking open relative openess of the system. You are the one always railing that medicine is not an open system and I am telling you I can get information in my state easier about a doctor than a lawyer.

  • Anonymous

    Railing about openness? What are you talking about?

    Again, which state are you in?