John Hickner, MD, MSc

Until recently, I was not a member of the American Medical Association (AMA). For the past 30 years, I chose not to join because I was troubled by the organization’s direction and the way it seemed to be dominated by special interests. But things have changed—and so has its focus.

The AMA has a new strategy entitled, “A vision for a healthier nation.” Well aligned with the needs of family physicians, the campaign addresses 3 specific areas: better patient health, smarter medical training, and sustainable practices.

Better patient health. The AMA is partnering with several public health-oriented organizations, including the Centers for Disease Control and Prevention, to reach out to individuals with diabetes, cardiovascular disease, and cardiac risk factors to promote primary and secondary prevention strategies at a population level. This is a very different posture than the AMA assumed in the early 20th century, when it was more likely to resist public health programs.

Smarter medical training. Under the direction of family physician Susan Skochelak, MD, MPH, group vice president for medical education, the AMA has provided grant funding to 31 US medical schools to assist with curricular redesign and innovation to train physicians to be effective leaders in the health care system of the future.

The new AMA is a different organization from the one I chose not to join for the past 30 years.

Sustainable practices. This area houses what is perhaps the AMA’s most meaningful new program for primary care clinicians. Under the leadership of general internist Christine A. Sinsky, MD, PhD, vice president for professional satisfaction, the AMA has developed a suite of Web tools to help physicians improve the quality and efficiency of their clinical practices.

Specifically, the AMA is offering the STEPS Forward program, a collection of interactive, educational modules developed by physicians for physicians to help address common practice challenges and to achieve the quadruple aim of a better patient experience, better population health, lower overall costs, and improved professional satisfaction.¹ The 27 modules are self-directed, group learning exercises that encompass a wide range of thorny issues we deal with on a daily basis. A sampling of topics includes: preparing your practice for change, revenue cycle management, synchronized prescription renewals, and creating a strong team culture.

Programs like these are evidence that the new AMA is a different organization from the one I chose not to join for the past 30 years. I am now a member. Check it out; it might be time for you to join, too.

Until recently, I was not a member of the American Medical Association (AMA). For the past 30 years, I chose not to join because I was troubled by the organization’s direction and the way it seemed to be dominated by special interests. But things have changed—and so has its focus.

The AMA has a new strategy entitled, “A vision for a healthier nation.” Well aligned with the needs of family physicians, the campaign addresses 3 specific areas: better patient health, smarter medical training, and sustainable practices.

Better patient health. The AMA is partnering with several public health-oriented organizations, including the Centers for Disease Control and Prevention, to reach out to individuals with diabetes, cardiovascular disease, and cardiac risk factors to promote primary and secondary prevention strategies at a population level. This is a very different posture than the AMA assumed in the early 20th century, when it was more likely to resist public health programs.

Smarter medical training. Under the direction of family physician Susan Skochelak, MD, MPH, group vice president for medical education, the AMA has provided grant funding to 31 US medical schools to assist with curricular redesign and innovation to train physicians to be effective leaders in the health care system of the future.

The new AMA is a different organization from the one I chose not to join for the past 30 years.

Sustainable practices. This area houses what is perhaps the AMA’s most meaningful new program for primary care clinicians. Under the leadership of general internist Christine A. Sinsky, MD, PhD, vice president for professional satisfaction, the AMA has developed a suite of Web tools to help physicians improve the quality and efficiency of their clinical practices.

Specifically, the AMA is offering the STEPS Forward program, a collection of interactive, educational modules developed by physicians for physicians to help address common practice challenges and to achieve the quadruple aim of a better patient experience, better population health, lower overall costs, and improved professional satisfaction.¹ The 27 modules are self-directed, group learning exercises that encompass a wide range of thorny issues we deal with on a daily basis. A sampling of topics includes: preparing your practice for change, revenue cycle management, synchronized prescription renewals, and creating a strong team culture.

Programs like these are evidence that the new AMA is a different organization from the one I chose not to join for the past 30 years. I am now a member. Check it out; it might be time for you to join, too.

Until recently, I was not a member of the American Medical Association (AMA). For the past 30 years, I chose not to join because I was troubled by the organization’s direction and the way it seemed to be dominated by special interests. But things have changed—and so has its focus.

The AMA has a new strategy entitled, “A vision for a healthier nation.” Well aligned with the needs of family physicians, the campaign addresses 3 specific areas: better patient health, smarter medical training, and sustainable practices.

Better patient health. The AMA is partnering with several public health-oriented organizations, including the Centers for Disease Control and Prevention, to reach out to individuals with diabetes, cardiovascular disease, and cardiac risk factors to promote primary and secondary prevention strategies at a population level. This is a very different posture than the AMA assumed in the early 20th century, when it was more likely to resist public health programs.

Smarter medical training. Under the direction of family physician Susan Skochelak, MD, MPH, group vice president for medical education, the AMA has provided grant funding to 31 US medical schools to assist with curricular redesign and innovation to train physicians to be effective leaders in the health care system of the future.

The new AMA is a different organization from the one I chose not to join for the past 30 years.

Sustainable practices. This area houses what is perhaps the AMA’s most meaningful new program for primary care clinicians. Under the leadership of general internist Christine A. Sinsky, MD, PhD, vice president for professional satisfaction, the AMA has developed a suite of Web tools to help physicians improve the quality and efficiency of their clinical practices.

Specifically, the AMA is offering the STEPS Forward program, a collection of interactive, educational modules developed by physicians for physicians to help address common practice challenges and to achieve the quadruple aim of a better patient experience, better population health, lower overall costs, and improved professional satisfaction.¹ The 27 modules are self-directed, group learning exercises that encompass a wide range of thorny issues we deal with on a daily basis. A sampling of topics includes: preparing your practice for change, revenue cycle management, synchronized prescription renewals, and creating a strong team culture.

Programs like these are evidence that the new AMA is a different organization from the one I chose not to join for the past 30 years. I am now a member. Check it out; it might be time for you to join, too.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

Echocardiograms were done, but who was reading them?

A 67-YEAR-OLD MAN had been under the care of his primary care physician for aortic stenosis. The physician was aware of this diagnosis and did periodic echocardiograms to monitor the patient’s heart. The patient was sent to a cardiologist for additional care. Over the next year and a half, the decedent’s condition worsened, and he died of heart failure.

PLAINTIFF’S CLAIM The defendants deviated from the standard of care in not reading the echocardiograms. If they had, they could have treated him and extended his life.

THE DEFENSE The cardiologist said it was not up to him to read the echocardiogram. The primary care physician acknowledged that he deviated from the standard of care.

VERDICT $3 million Connecticut verdict.

Don't assume the specialist has taken charge; verify or manage the patient yourself.

COMMENT This is a clear case of failure to take responsibility. I suspect the failure was based on the assumption by both physicians that the other physician was monitoring the patient’s status.

This happened to me with a patient who gradually drifted into acute heart failure while I assumed the nephrologist was managing his diuretics. A phone call and more furosemide would have prevented that hospital admission. (Luckily, my patient recovered uneventfully.)

Don’t assume the specialist has taken charge; verify or manage the patient yourself.

Third call to help line finally leads to office visit, but it’s too late

A 42-YEAR-OLD WOMAN called a phone help line and told a nurse that she had a fever, chills, sore throat, and severe chest pain. The next day she called again and spoke with a nurse who routed her call to a physician. The physician diagnosed the woman with influenza during their 4-minute conversation. She called again the next day and was told to come in for examination. The woman did so and was admitted. One day later, she died of sepsis secondary to pneumonia.

PLAINTIFF’S CLAIM The standard of care required immediate examination by the time of the second call.

THE DEFENSE The plaintiff did not actually report chest pain until the second call, and she contracted an unusually fast-acting strain of pneumonia.

VERDICT $3.5 million California arbitration award.

COMMENT Delayed diagnosis is one of the main reasons family physicians are successfully sued. Management of this patient may have been reasonable the first day. The second call should have prompted a same day visit or instructions to go to the emergency department or at least an urgent care facility. The third call was too late.

In September 2015, the Centers for Medicare & Medicaid Services (CMS) launched a promising 4-year program called the "Transforming Clinical Practice Initiative" to lighten the load for family physicians.¹ The central figures in this program are skilled and trained quality improvement advisors (QIA) who will work directly with physicians and their staffs to assist with the heavy lifting of practice improvement. The Oklahoma Physicians Research and Resources Network has used QIAs, which it calls practice enhancement assistants (PEAs), for more than 20 years to help Oklahoma family physicians improve various aspects of their practices, including testing processes, diabetes care, and preventive services. The PEAs have been enormously helpful.²

For this new CMS program, the feds awarded $685 million to 39 national and regional collaborative health care transformation networks and supporting organizations to develop peer-based learning networks to facilitate practice improvements.¹ The program is designed to help more than 140,000 primary care physicians improve their practices by providing an extra set of skilled hands.

The new CMS initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates.

The American Board of Family Medicine (ABFM) and the American Academy of Family Physicians (AAFP) have teamed up to assist with this national effort. ABFM will cover the cost for the first 6000 family physicians who enroll in one of the regional Practice Transformation Networks to use their newly developed chronic disease registry called PRIME. This registry will extract clinical quality data from diverse electronic health records and report back to practices. The registry will meet the new federal quality measures reporting requirements and will also be a path for maintenance of certification.

The CMS Transforming Clinical Practice Initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates and make your office more efficient and enjoyable for you, your staff, and your patients. Contact the ABFM (www.theabfm.org) to find out which organization is running the Practice Transformation Network in your area.

In September 2015, the Centers for Medicare & Medicaid Services (CMS) launched a promising 4-year program called the "Transforming Clinical Practice Initiative" to lighten the load for family physicians.¹ The central figures in this program are skilled and trained quality improvement advisors (QIA) who will work directly with physicians and their staffs to assist with the heavy lifting of practice improvement. The Oklahoma Physicians Research and Resources Network has used QIAs, which it calls practice enhancement assistants (PEAs), for more than 20 years to help Oklahoma family physicians improve various aspects of their practices, including testing processes, diabetes care, and preventive services. The PEAs have been enormously helpful.²

For this new CMS program, the feds awarded $685 million to 39 national and regional collaborative health care transformation networks and supporting organizations to develop peer-based learning networks to facilitate practice improvements.¹ The program is designed to help more than 140,000 primary care physicians improve their practices by providing an extra set of skilled hands.

The new CMS initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates.

The American Board of Family Medicine (ABFM) and the American Academy of Family Physicians (AAFP) have teamed up to assist with this national effort. ABFM will cover the cost for the first 6000 family physicians who enroll in one of the regional Practice Transformation Networks to use their newly developed chronic disease registry called PRIME. This registry will extract clinical quality data from diverse electronic health records and report back to practices. The registry will meet the new federal quality measures reporting requirements and will also be a path for maintenance of certification.

The CMS Transforming Clinical Practice Initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates and make your office more efficient and enjoyable for you, your staff, and your patients. Contact the ABFM (www.theabfm.org) to find out which organization is running the Practice Transformation Network in your area.

In September 2015, the Centers for Medicare & Medicaid Services (CMS) launched a promising 4-year program called the "Transforming Clinical Practice Initiative" to lighten the load for family physicians.¹ The central figures in this program are skilled and trained quality improvement advisors (QIA) who will work directly with physicians and their staffs to assist with the heavy lifting of practice improvement. The Oklahoma Physicians Research and Resources Network has used QIAs, which it calls practice enhancement assistants (PEAs), for more than 20 years to help Oklahoma family physicians improve various aspects of their practices, including testing processes, diabetes care, and preventive services. The PEAs have been enormously helpful.²

For this new CMS program, the feds awarded $685 million to 39 national and regional collaborative health care transformation networks and supporting organizations to develop peer-based learning networks to facilitate practice improvements.¹ The program is designed to help more than 140,000 primary care physicians improve their practices by providing an extra set of skilled hands.

The new CMS initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates.

The American Board of Family Medicine (ABFM) and the American Academy of Family Physicians (AAFP) have teamed up to assist with this national effort. ABFM will cover the cost for the first 6000 family physicians who enroll in one of the regional Practice Transformation Networks to use their newly developed chronic disease registry called PRIME. This registry will extract clinical quality data from diverse electronic health records and report back to practices. The registry will meet the new federal quality measures reporting requirements and will also be a path for maintenance of certification.

The CMS Transforming Clinical Practice Initiative is a great opportunity to get that extra set of skilled hands you need to help meet new quality mandates and make your office more efficient and enjoyable for you, your staff, and your patients. Contact the ABFM (www.theabfm.org) to find out which organization is running the Practice Transformation Network in your area.

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

While some physicians prefer a narrower clinic focus, the wide variety and complexity of the care provided by family physicians is precisely what drew many of us to the specialty. We enjoy caring for patients of all ages who see us for the diagnosis and treatment of acute illnesses, management of chronic diseases, preventive care, and behavioral and mental health concerns.

The quantity, variety, and complexity of the care we provide has been well-documented in the literature. In a study performed by the Wisconsin Research Network,¹ 29 family physicians reported addressing an average of 3.05 problems per patient during 572 office visits. A chart review confirmed physician self-report: 2.82 problems were recorded on average for each visit. For patients older than age 65, an average of 3.88 problems were addressed at each visit. For patients with diabetes, the average was 4.60.

Using data from the 2000 National Ambulatory Medical Care Survey, Katerndahl et al² estimated the complexity of patient encounters in family practice, cardiology, and psychiatry. They used a formula that took into account the per-patient number of reasons for each visit, diagnoses, and body systems examined, and the variability and diversity of each of these factors. After adjusting the results for length of visit, they found the complexity of care provided per hour by family physicians was 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

The topics in this issue are a terrific illustration of the breadth of family medicine. Peripheral neuropathy, which we see almost daily, is difficult to diagnose and treat. Prolotherapy is an up-and-coming dextrose injection therapy for tendinopathies and joint pain that shows promise, and patients are likely to start asking us about it. Home apnea monitors are used frequently for newborns—but how effective are they, and when can you tell parents to discontinue their use?

The complexity of care provided per hour by family physicians is 33% higher than that of cardiologists and 5 times higher than that of psychiatrists.

It seems that vaccine recommendations change every year, and this issue’s Practice Alert covers the latest on meningococcal immunization. This month’s PURL answers the question: Do we really need to “bridge” patients with atrial fibrillation from warfarin to low molecular weight heparin immediately before and after a surgical procedure?

The authors and editors of The Journal of Family Practice constantly strive to bring you the most up-to-date information to support your work as a master of the complexity of primary care practice.

Was this CT with contrast unnecessary—and harmful?

A 52-YEAR-OLD WOMAN presented to the emergency department (ED) with leg pain and vaginal bleeding. The ED physicians ordered a computed tomography (CT) scan with contrast. Following the administration of the contrast dye, the patient’s blood pressure spiked and a brain aneurysm ruptured. The patient immediately underwent cranial surgery and recovered well. However, she still suffers from paralysis, cognitive issues, and weakness in her left arm and leg. She has been unable to return to her job.

PLAINTIFF’S CLAIM The doctors ran several unnecessary tests, including the CT scan, which caused her to have an allergic reaction.

THE DEFENSE The CT scan was necessary to rule out a stomach abscess, and the ruptured aneurysm was caused by her medical condition and not the dye.

VERDICT $3.62 million New Jersey verdict.

This is a sober reminder that doing more tests does not protect one from litigation.

COMMENT Here is a sober reminder that doing more tests does not protect one from litigation. We are not told enough in this short report to know if there was a legitimate indication for a CT scan, but the large award suggests there was not. The Choosing Wisely campaign (http://www.choosingwisely.org), which has a goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures,” is not just about saving money—it is about practicing medicine appropriately.

Patient dies after being prescribed opioids right after detoxification

A 52-YEAR-OLD WOMAN had been going to the same physician for 17 years. While she was under his care, she had been prescribed various narcotics, benzodiazepines, and barbiturates, and she had become addicted to them. The patient suffered a fall at home that was allegedly caused by an overdose of these medications. During a 3-week hospitalization after her fall, the woman went through a detoxification protocol to ease her dependence on the drugs. During her next appointment with her physician, he prescribed alprazolam and morphine sulfate daily. A week later, the woman died, allegedly due to an overdose of the alprazolam and morphine sulfate.

PLAINTIFF’S CLAIM The defendant’s failure to investigate the reason for the decedent’s hospitalization violated the standard of care. If the physician had inquired about his patient’s recent hospitalization, he would have been told about her detoxification, and wouldn’t have prescribed her any potentially addictive drugs.

THE DEFENSE The physician admitted that if he had known about his patient’s detoxification, he would not have prescribed her any medication. However, the doctor in charge of overseeing the detoxification told the patient not to see the defendant again, and not to take any prescriptions from him.

VERDICT $156,853 Illinois verdict.

COMMENT There is good reason to be wary of prescribing strong opioids and benzodiazepines for chronic pain in primary care practice. With the sharp increase in overdose deaths from opioids and the marginal evidence, at best, that supports the use of opioids for chronic, nonmalignant pain, such patients should—in my opinion—be managed directly in a pain/addiction program, or in close collaboration with one.

State Boards of Medicine are becoming appropriately stringent about opioids, so don’t risk losing your medical license or being sued. Use narcotic-use contracts, random drug testing, and co-management, and check your state narcotic prescribing database regularly if you treat chronic pain patients.

Was this CT with contrast unnecessary—and harmful?

A 52-YEAR-OLD WOMAN presented to the emergency department (ED) with leg pain and vaginal bleeding. The ED physicians ordered a computed tomography (CT) scan with contrast. Following the administration of the contrast dye, the patient’s blood pressure spiked and a brain aneurysm ruptured. The patient immediately underwent cranial surgery and recovered well. However, she still suffers from paralysis, cognitive issues, and weakness in her left arm and leg. She has been unable to return to her job.

PLAINTIFF’S CLAIM The doctors ran several unnecessary tests, including the CT scan, which caused her to have an allergic reaction.

THE DEFENSE The CT scan was necessary to rule out a stomach abscess, and the ruptured aneurysm was caused by her medical condition and not the dye.

VERDICT $3.62 million New Jersey verdict.

This is a sober reminder that doing more tests does not protect one from litigation.

COMMENT Here is a sober reminder that doing more tests does not protect one from litigation. We are not told enough in this short report to know if there was a legitimate indication for a CT scan, but the large award suggests there was not. The Choosing Wisely campaign (http://www.choosingwisely.org), which has a goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures,” is not just about saving money—it is about practicing medicine appropriately.

Patient dies after being prescribed opioids right after detoxification

A 52-YEAR-OLD WOMAN had been going to the same physician for 17 years. While she was under his care, she had been prescribed various narcotics, benzodiazepines, and barbiturates, and she had become addicted to them. The patient suffered a fall at home that was allegedly caused by an overdose of these medications. During a 3-week hospitalization after her fall, the woman went through a detoxification protocol to ease her dependence on the drugs. During her next appointment with her physician, he prescribed alprazolam and morphine sulfate daily. A week later, the woman died, allegedly due to an overdose of the alprazolam and morphine sulfate.

PLAINTIFF’S CLAIM The defendant’s failure to investigate the reason for the decedent’s hospitalization violated the standard of care. If the physician had inquired about his patient’s recent hospitalization, he would have been told about her detoxification, and wouldn’t have prescribed her any potentially addictive drugs.

THE DEFENSE The physician admitted that if he had known about his patient’s detoxification, he would not have prescribed her any medication. However, the doctor in charge of overseeing the detoxification told the patient not to see the defendant again, and not to take any prescriptions from him.

VERDICT $156,853 Illinois verdict.

COMMENT There is good reason to be wary of prescribing strong opioids and benzodiazepines for chronic pain in primary care practice. With the sharp increase in overdose deaths from opioids and the marginal evidence, at best, that supports the use of opioids for chronic, nonmalignant pain, such patients should—in my opinion—be managed directly in a pain/addiction program, or in close collaboration with one.

State Boards of Medicine are becoming appropriately stringent about opioids, so don’t risk losing your medical license or being sued. Use narcotic-use contracts, random drug testing, and co-management, and check your state narcotic prescribing database regularly if you treat chronic pain patients.

Was this CT with contrast unnecessary—and harmful?

A 52-YEAR-OLD WOMAN presented to the emergency department (ED) with leg pain and vaginal bleeding. The ED physicians ordered a computed tomography (CT) scan with contrast. Following the administration of the contrast dye, the patient’s blood pressure spiked and a brain aneurysm ruptured. The patient immediately underwent cranial surgery and recovered well. However, she still suffers from paralysis, cognitive issues, and weakness in her left arm and leg. She has been unable to return to her job.

PLAINTIFF’S CLAIM The doctors ran several unnecessary tests, including the CT scan, which caused her to have an allergic reaction.

THE DEFENSE The CT scan was necessary to rule out a stomach abscess, and the ruptured aneurysm was caused by her medical condition and not the dye.

VERDICT $3.62 million New Jersey verdict.

This is a sober reminder that doing more tests does not protect one from litigation.

COMMENT Here is a sober reminder that doing more tests does not protect one from litigation. We are not told enough in this short report to know if there was a legitimate indication for a CT scan, but the large award suggests there was not. The Choosing Wisely campaign (http://www.choosingwisely.org), which has a goal of “advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures,” is not just about saving money—it is about practicing medicine appropriately.

Patient dies after being prescribed opioids right after detoxification

A 52-YEAR-OLD WOMAN had been going to the same physician for 17 years. While she was under his care, she had been prescribed various narcotics, benzodiazepines, and barbiturates, and she had become addicted to them. The patient suffered a fall at home that was allegedly caused by an overdose of these medications. During a 3-week hospitalization after her fall, the woman went through a detoxification protocol to ease her dependence on the drugs. During her next appointment with her physician, he prescribed alprazolam and morphine sulfate daily. A week later, the woman died, allegedly due to an overdose of the alprazolam and morphine sulfate.

PLAINTIFF’S CLAIM The defendant’s failure to investigate the reason for the decedent’s hospitalization violated the standard of care. If the physician had inquired about his patient’s recent hospitalization, he would have been told about her detoxification, and wouldn’t have prescribed her any potentially addictive drugs.

THE DEFENSE The physician admitted that if he had known about his patient’s detoxification, he would not have prescribed her any medication. However, the doctor in charge of overseeing the detoxification told the patient not to see the defendant again, and not to take any prescriptions from him.

VERDICT $156,853 Illinois verdict.

COMMENT There is good reason to be wary of prescribing strong opioids and benzodiazepines for chronic pain in primary care practice. With the sharp increase in overdose deaths from opioids and the marginal evidence, at best, that supports the use of opioids for chronic, nonmalignant pain, such patients should—in my opinion—be managed directly in a pain/addiction program, or in close collaboration with one.

State Boards of Medicine are becoming appropriately stringent about opioids, so don’t risk losing your medical license or being sued. Use narcotic-use contracts, random drug testing, and co-management, and check your state narcotic prescribing database regularly if you treat chronic pain patients.

It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”

At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”

He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”

Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.

I follow his example, and patients regularly thank me for truly listening to them.

It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”

At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”

He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”

Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.

I follow his example, and patients regularly thank me for truly listening to them.

It seems like every time I ask a family physician how things are going, the electronic medical record (EMR) inevitably rears its ugly face. At the annual Illinois Academy of Family Physicians business meeting last month, one of the physicians lamented the evenings he spends finishing his charting. A family physician I consider a master user of EMRs e-mailed me recently, saying he is fed up with documentation expectations for coding, billing, meaningful use, and quality measures. He wrote, “We are challenged by good intentions but crushingly poor execution … and it is taking its toll.”

At the 2015 American Academy of Family Physicians Family Medicine Expo, keynote speaker, general internist, and bestselling author Abraham Verghese, MD, talked about the “iPatient.” He said, “The patient in the bed has become a mere icon for the ‘real patient’ who is in the computer. The iPatient is getting wonderful care all across America. The real patient is wondering where the heck is everyone and when are they going to tell me what is going on.”

He had received this comment from a patient: “When I go to my doctor’s office, I have to remind him that I am hard of hearing and need him to look at me when I talk. But it only lasts about 30 seconds until he needs to shift back to the competing screen.”

Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Patients don’t like us attending to the screen instead of to them. The observational study of 126 primary care encounters by Farber et al in this issue supports this assertion. Although Farber et al found that patients’ satisfaction with their primary care physician or nurse practitioner was high overall, patients were even more satisfied with their office visit when the clinician spent more time looking at them. Patients want to engage in a face-to-face conversation, not face-to-back or face-to-side-of-head.

Until clever innovators figure out a much better way to document patient visits, there are ways to overcome this patient-physician-computer screen triangle. Take my optometrist, for example. He opens my EMR at the beginning of the visit to take a quick look, but doesn’t return to the computer until the end of the visit. When he does the charting, he excuses himself and says, “I need to enter some information in the computer. It will take me a few minutes.” I pull out my cell phone to check e-mails while he types.

I follow his example, and patients regularly thank me for truly listening to them.

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.

Last month, a group of investigators from the American Academy of Family Physicians and the University of Wisconsin led by Holman¹ published a study entitled, “The myth of standardized workflow in primary care.” The researchers directly observed 20 primary care physician (PCP) visits and coded the usual tasks physicians perform during a visit. For some physicians, they observed 2 encounters to see if individual physicians followed a consistent pattern. What they found won’t surprise any of you:

“…We found no consistent workflows when analyzing visits individually or by PCP, or visits conducted at clinics with or without an [electronic medical record (EMR)]. The workflow for tasks is dictated not by the type of chart, the patient, or the physician. Instead, workflow emerges from the interaction between the patient’s and the physician’s agendas.”

This rang true for me. For example, sometimes a patient immediately pulls out her bag of pills, so I do the medication review first. Other times, social chat comes first. Often, asking, “Is there anything else you need today?” leads to another round of history-taking and test-ordering.

The physicians in this study approached patient visits as a conversation rather than adhering to a rigid protocol, as the EMR vendors imply we should do. Frankly, that has never made sense to me. Why shouldn’t the EMR companies adapt their tools to the needs of patients and physicians? It was so heartening to read that experienced family physicians are not kowtowing to EMR experts’ insistence that we change our workflow to adapt to the realities of EMRs. We still approach patient encounters in a patient-centered way, following the thread of the conversation to fully respond to our patients’ needs. (Can the same be said for medical students? See last month’s Guest Editorial, “Med students: Look up from your EMRs”.)

"Workflow" was a foreign concept to me until the advent of EMRs. I never worried much about the order in which I was performing "tasks," and I still don't.

Holman et al¹ describe the interplay between physicians and patients during office visits as a “dance” in which patients and physicians take turns leading. Let’s invite EMR vendors to join our dance—and follow our lead.

Should these complaints have prompted a colonoscopy?

A 45-YEAR-OLD WOMAN went to her primary care physician due to cramping abdominal pain after eating. She hadn’t seen her physician in 5 years and noted that her bowel movements were somewhat smaller than usual. Her physician suspected an ulcer and treated her with acid-reducing medication.

A month later, the patient returned with similar symptoms and said that her bowel movements were somewhat loose. The physician increased the dosage of the acid-reducing medication. The patient returned again a month later and reported constipation. The stomach issues continued and she was referred to a gynecologist. Ultimately, she went to a gastroenterologist and underwent a colonoscopy 8 months after her first visit. She was diagnosed with stage IV colon cancer with metastasis to the ovaries. The patient passed away 8 years later.

PLAINTIFF’S CLAIM The physician was negligent in failing to suspect colon cancer and perform a colonoscopy, digital rectal exam, or fecal occult blood test.

THE DEFENSE The decedent’s symptoms were inconsistent with cancer and did not indicate the need for a colonoscopy. The cancer was already advanced and the outcome would not have changed.

VERDICT $2.16 million Massachusetts verdict.

COMMENT Wow, this is a tough one! I am not at all sure I would have diagnosed this correctly. Is there a lesson here? Perhaps the history was not sufficiently thorough? Perhaps these were totally new symptoms that should have demanded a more thorough investigation? Or perhaps it would have taken 4 to 6 months for any of us to make this diagnosis in a 45-year-old woman.

Complication of pregnancy goes undetected after delivery 

A 31-YEAR-OLD WOMAN went to the emergency department (ED) complaining of tightness in her chest, difficulty breathing, and swelling in her lower legs 4 days after she delivered a child. The ED physician ruled out a pulmonary embolism and discharged her. Three days later, she returned with the same symptoms, but her legs were more swollen and her systolic blood pressure was above 160 mm Hg. She was sent home again. The woman had a seizure 4 days later. In the ambulance on the way to the hospital and following her arrival, she suffered more seizures. A few days later, she was transferred to a different facility and died soon after.

PLAINTIFF’S CLAIM The hospital and 2 ED physicians were negligent in failing to diagnose and treat postpartum preeclampsia during the ED visits. This led to the seizures, brain damage, and death. Antihypertensive and anti-seizure medications would have prevented her death.

THE DEFENSE The actions taken were reasonable, especially because the decedent had no symptoms of preeclampsia during pregnancy or delivery.

VERDICT $6.9 million Illinois settlement.

COMMENT This case speaks for itself. The physicians involved appear to have had a knowledge gap since they apparently did not consider preeclampsia in the differential. Primary care physicians and emergency physicians must be trained to recognize complications of pregnancy.

Should these complaints have prompted a colonoscopy?

A 45-YEAR-OLD WOMAN went to her primary care physician due to cramping abdominal pain after eating. She hadn’t seen her physician in 5 years and noted that her bowel movements were somewhat smaller than usual. Her physician suspected an ulcer and treated her with acid-reducing medication.

A month later, the patient returned with similar symptoms and said that her bowel movements were somewhat loose. The physician increased the dosage of the acid-reducing medication. The patient returned again a month later and reported constipation. The stomach issues continued and she was referred to a gynecologist. Ultimately, she went to a gastroenterologist and underwent a colonoscopy 8 months after her first visit. She was diagnosed with stage IV colon cancer with metastasis to the ovaries. The patient passed away 8 years later.

PLAINTIFF’S CLAIM The physician was negligent in failing to suspect colon cancer and perform a colonoscopy, digital rectal exam, or fecal occult blood test.

THE DEFENSE The decedent’s symptoms were inconsistent with cancer and did not indicate the need for a colonoscopy. The cancer was already advanced and the outcome would not have changed.

VERDICT $2.16 million Massachusetts verdict.

COMMENT Wow, this is a tough one! I am not at all sure I would have diagnosed this correctly. Is there a lesson here? Perhaps the history was not sufficiently thorough? Perhaps these were totally new symptoms that should have demanded a more thorough investigation? Or perhaps it would have taken 4 to 6 months for any of us to make this diagnosis in a 45-year-old woman.

Complication of pregnancy goes undetected after delivery 

A 31-YEAR-OLD WOMAN went to the emergency department (ED) complaining of tightness in her chest, difficulty breathing, and swelling in her lower legs 4 days after she delivered a child. The ED physician ruled out a pulmonary embolism and discharged her. Three days later, she returned with the same symptoms, but her legs were more swollen and her systolic blood pressure was above 160 mm Hg. She was sent home again. The woman had a seizure 4 days later. In the ambulance on the way to the hospital and following her arrival, she suffered more seizures. A few days later, she was transferred to a different facility and died soon after.

PLAINTIFF’S CLAIM The hospital and 2 ED physicians were negligent in failing to diagnose and treat postpartum preeclampsia during the ED visits. This led to the seizures, brain damage, and death. Antihypertensive and anti-seizure medications would have prevented her death.

THE DEFENSE The actions taken were reasonable, especially because the decedent had no symptoms of preeclampsia during pregnancy or delivery.

VERDICT $6.9 million Illinois settlement.

COMMENT This case speaks for itself. The physicians involved appear to have had a knowledge gap since they apparently did not consider preeclampsia in the differential. Primary care physicians and emergency physicians must be trained to recognize complications of pregnancy.

Should these complaints have prompted a colonoscopy?

A 45-YEAR-OLD WOMAN went to her primary care physician due to cramping abdominal pain after eating. She hadn’t seen her physician in 5 years and noted that her bowel movements were somewhat smaller than usual. Her physician suspected an ulcer and treated her with acid-reducing medication.

A month later, the patient returned with similar symptoms and said that her bowel movements were somewhat loose. The physician increased the dosage of the acid-reducing medication. The patient returned again a month later and reported constipation. The stomach issues continued and she was referred to a gynecologist. Ultimately, she went to a gastroenterologist and underwent a colonoscopy 8 months after her first visit. She was diagnosed with stage IV colon cancer with metastasis to the ovaries. The patient passed away 8 years later.

PLAINTIFF’S CLAIM The physician was negligent in failing to suspect colon cancer and perform a colonoscopy, digital rectal exam, or fecal occult blood test.

THE DEFENSE The decedent’s symptoms were inconsistent with cancer and did not indicate the need for a colonoscopy. The cancer was already advanced and the outcome would not have changed.

VERDICT $2.16 million Massachusetts verdict.

COMMENT Wow, this is a tough one! I am not at all sure I would have diagnosed this correctly. Is there a lesson here? Perhaps the history was not sufficiently thorough? Perhaps these were totally new symptoms that should have demanded a more thorough investigation? Or perhaps it would have taken 4 to 6 months for any of us to make this diagnosis in a 45-year-old woman.

Complication of pregnancy goes undetected after delivery 

A 31-YEAR-OLD WOMAN went to the emergency department (ED) complaining of tightness in her chest, difficulty breathing, and swelling in her lower legs 4 days after she delivered a child. The ED physician ruled out a pulmonary embolism and discharged her. Three days later, she returned with the same symptoms, but her legs were more swollen and her systolic blood pressure was above 160 mm Hg. She was sent home again. The woman had a seizure 4 days later. In the ambulance on the way to the hospital and following her arrival, she suffered more seizures. A few days later, she was transferred to a different facility and died soon after.

PLAINTIFF’S CLAIM The hospital and 2 ED physicians were negligent in failing to diagnose and treat postpartum preeclampsia during the ED visits. This led to the seizures, brain damage, and death. Antihypertensive and anti-seizure medications would have prevented her death.

THE DEFENSE The actions taken were reasonable, especially because the decedent had no symptoms of preeclampsia during pregnancy or delivery.

VERDICT $6.9 million Illinois settlement.

COMMENT This case speaks for itself. The physicians involved appear to have had a knowledge gap since they apparently did not consider preeclampsia in the differential. Primary care physicians and emergency physicians must be trained to recognize complications of pregnancy.