Four cases to test your malpractice IQ
I will highlight one case:

Early one afternoon, you examine a 4-year-old boy who has abdominal pain. His parents fear appendicitis, yet they report no fever, nausea, or vomiting. Your physical exam reveals no rebound tenderness or guarding, and the white count is normal. You conclude that it’s an upset stomach, but the worried parents aren’t satisfied. They want a referral to a surgeon. Instead, you persuade them to monitor the boy, and to call if the pain gets worse.

The parents call that night reporting their son’s severe pain. When you meet them in the ED, you realize that you’re dealing with a ruptured appendix, and call in a surgeon. The child has a stormy post-op course, and a prolonged hospital stay. The parents sue, claiming you missed the appendicitis, and should have referred their son sooner. How should you have managed this case?

A. By referring the patient as the parents requested.

B. By relying as you did on your professional judgment.

Option “A” would be the “defensive referral” option. “Referral to a surgeon” could just as easily be “order a CT scan” despite normal clinical findings. Not surprisingly, it was recommended that the physician go with the first option. Clinical suspicion has very little role today. Cya referrals and comprehensive imaging seems to be the way to go:

The wiser course would have been A. Primary care physicians often resent being used as mere referral agents. But whenever a patient expresses reservations about either your diagnosis or treatment, you should recognize a red flag and make a prompt referral. Professional pride doesn’t help in malpractice prevention or defense.

If you had made the referral promptly, and the surgeon had agreed with your diagnosis, the parents couldn’t have faulted you. If he had spotted the appendicitis the same day, the whole misadventure might have been avoided.