In anticipation of American Heart Month, an examination of the liability risks faced by cardiologists was recently undertaken by The Doctors Company, the nation’s largest physician-owned medical malpractice insurer. This analysis of 429 closed cardiology claims from 2007 to 2013 revealed that the most common patient allegations against cardiologists and other clinicians were diagnostic errors, followed closely by procedural or surgical mishaps. This data is of particular interest to cardiologists, but other clinicians should take note — many different specialties are also routinely caught up in lawsuits against cardiologists. For example, in a separate study of claims based on cardiac conditions, cardiologists were identified in 22 percent of cardiac claims while internists were identified in 19 percent of these claims. In addition, the wide diversity of claims against cardiologists may offer a representative cross section of the liability pitfalls facing all clinicians.
The most common allegation in a cardiology claim, diagnostic error, includes the failure or delay in ordering a test or failure to establish a differential diagnosis. Unfortunately, errors in the diagnosis of a heart condition are common, and not restricted to cardiologists. Primary care physicians face the same conditions and allegations in cardiac-related claims.
Failure to diagnose myocardial infarction can be a particular pitfall for non-cardiologists, while for cardiologists, the primary danger is failure to diagnose “pretenders” such as pulmonary embolism presenting as shortness of breath, aortic dissection presenting as chest pain, or even cancer presenting with non-specific symptoms. Failing to follow up on imaging studies can be a significant liability hazard. A recurrent scenario is that of a physician who fails to follow up on an incidental mass found on a chest x-ray or CT scan; it is eventually discovered by another provider and found to be late-stage cancer. Specialists sometimes have too narrow a focus, and this data reminds us of the cost of failing to look at the larger picture.
For lawsuits associated with procedures, different lessons can be gleaned from the data. Many of these lawsuits are frustrating because often the injury is a known complication. Complications will occur, even for the most experienced and skilled practitioners who are meeting the standard of care. It’s imperative for clinicians and patients to have real informed consent discussions and for clinicians to verify that patients can repeat back the risks of the procedure.
Medication errors also constitute a large proportion of these lawsuits. Document all discussions with patients regarding side effects, particularly when you choose a high-risk, liability-prone medication such as Coumadin. Choosing a high-risk medicine is perfectly acceptable, but it is helpful to document the reasons why you are prescribing this medication; all medications have trade-offs (for example, bleeding vs. stroke), and these risks should be made explicit during the informed consent discussion. Be willing to answer any questions patients may have regarding their care.
Mismanagement of non-cardiac issues identified in cardiac patients is another liability pitfall, particularly when following up on a possible cancer diagnosis or the improper use of non-cardiac medication. Physicians should document all discussions about clinical findings even if the treatment is outside of their specialty area.
Physicians and patients need to work together. Failure to follow up and provide intensive patient management can lead to missed or delayed diagnoses, accelerated disease symptoms, morbidity, and/or mortality. Alternatively, patients who do not follow their treatment plan may experience a setback in their recovery, which could result in increased liability for the clinician.
Lawsuits are going to happen. In this analysis, one often finds cases where physicians clearly met the standard of care and were still sued.
Ideally, this data will help cardiologists and other practitioners become more cognizant of factors that increase their chances of a lawsuit. Through this data, we gain a sense of specific clinical scenarios that increase our risks and are able to take steps like meticulous informed consent that will improve quality and patient safety.
Sandeep Mangalmurti is a cardiologist and lead researcher, American College of Cardiology Medical Liability Working Group.