Facts of the Case
The patient, a 38-year-old male, came to see the internist complaining of back pain on four occasions in one month. The patient had a history of alcohol dependence, depression and Vicodin use/abuse. The internist’s assessment of the patient’s back pain was not very detailed or adequate. He did not order x-rays, refer the patient for physical therapy nor refer the patient to an orthopedic surgeon for treatment of the pain. Also, although the patient did have a history of Vicodin use/abuse, the internist still prescribed Vicodin for the back pain.
Several months later, after continuing to prescribe this narcotic despite no diagnosis of the source of the pain, the internist documented that the patient was addicted to Vicodin. Although he assessed the patient’s mental status as being depressed, the internist documented that the patient was not homicidal or suicidal. He then spent thirty minutes “counseling” the patient. The internist also referred him to the emergency department to be admitted to either a psychiatric unit or a detoxification unit. However, the patient declined to be admitted for inpatient treatment of his depression and addiction. Because of the patient’s refusal, the internist ordered Clonidine and Symbyax for detoxification, and the patient was asked to return in two days, which he did.
The internist documented that the patient was again depressed and further complained of insomnia and anxiety but “denied suicidal or homicidal ideation.” The internist made an appointment for the patient to voluntarily enter a detoxification unit that day. However, the patient’s wife called the internist later in the day and told him that the patient had refused to be admitted to the hospital detoxification unit. The internist took no further action at that time.
Three days later, the patient killed himself with a gunshot wound to the head. The wife of the deceased patient commenced a lawsuit against the defendant internist for negligent treatment and failure to prevent the patient’s suicide.
Expert Reviews
The case was reviewed by an expert in internal medicine. His evaluation of the care provided was very critical. He determined that the defendant did not adequately assess the cause of the patient’s back pain, nor did he refer the patient to an orthopedic specialist for diagnosis and treatment. The expert was particularly concerned about the casual prescription of Vicodin for back pain of unknown origin. His major criticism involved the defendant’s failure to refer the patient to a psychiatrist instead of performing “counseling” and treating a severely depressed patient with various medications.
The case was also reviewed by an expert in psychiatry. He, too, was very concerned about the care provided. He criticized the defendant’s ability and attempts to treat a patient with an obviously serious psychiatric illness rather than seeking to have him involuntarily admitted for psychiatric treatment in a timelier manner. He also criticized the fact that the defendant had treated the patient, who had known depression and addictive tendencies, with narcotics for an undiagnosed condition for more than three months.
An additional very serious problem in the defense of this case was the fact that the internist rewrote his records shortly after the patient committed suicide. The rewritten records emphasized the multiple attempts of the defendant to have the patient voluntarily undergo detoxification and/or psychiatric inpatient treatment.
Because of the serious deficits found in the defendant’s care of this patient and the difficulties in defending the defendant, the case was settled for $925,000. The age of the patient and the fact that he had a family to support contributed, in part, to the size of the settlement.
Legal Analysis
The defendant internist, in this case, chose to treat his patient’s mental health condition and addiction himself instead of referring him to a specialist. As this case demonstrates, this course of action carries many pitfalls.
This patient came to the defendant with a history of alcohol dependence, depression and narcotic use/abuse. These conditions should have raised a red flag in the defendant’s mind that this patient would best be served by being under the care of a specialist. However, rather than immediately referring the patient to any specialist, the defendant chose to treat the patient himself. He continued the patient’s controlled substance prescription for months and failed to make any referrals to identify the underlying cause of the back pain, which had resulted in narcotic use. So, too, even though the defendant assessed the patient’s mental status as depressed, he did not refer the patient to a mental health professional and instead attempted informal “counseling.”
It almost goes without saying that primary care physicians who have patients with mental health and addiction issues should be especially confident that they have the training and competence to manage these issues. Here, the patient’s history of depression, insomnia and anxiety, along with his longstanding narcotic dependence, should have alerted the defendant that the patient needed timely specialized care. When the patient refused to be admitted for inpatient treatment of his addiction, the defendant took it upon himself to prescribe medications for detoxification. The wife’s call that the patient again refused to enter an inpatient program should have underscored the need for swift follow-up since the patient had been compliant in keeping prior office visits.
Finally, once a medical record is shown to have been altered, it leaves the impression that the defendant’s statements and version of events cannot be trusted. It is incredibly damaging to the defense of any malpractice case and, in part, contributed to the high settlement in this case.
MLMIC policyholders can reach our healthcare attorneys for questions regarding proper documentation, referring a patient to a specialist or any other healthcare law inquiries by calling (800) 275-6564 Monday-Friday, 8 a.m. to 6 p.m., or by emailing here.
Our 24/7 hotline is also available for urgent matters after hours at (844) 667-5291 or by emailing hotline@tmglawny.com.
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This document is for general purposes only and should not be construed as medical or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical or professional obligations, the applicable state or federal laws or other professional questions.
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