The Blurred Lines of Care: Friendship, Medicine and a Fatal Outcome

Fact of the Case

A 55-year-old married contractor and volunteer firefighter with two children was initially seen by the defendant family physician on April 24, 2002. The physician’s children and those of the patient were friends and on the same sports teams. The physician had also treated the patient’s wife and siblings. Additionally, the patient had performed work for the physician.

The family physician documented the patient’s past medical history of hypertension, a weight of 208 pounds and a blood pressure of 142/102. His physical examination revealed a clear chest and regular heart rate. Lopressor and Enalapril were prescribed, and a six-week return appointment was scheduled.

The patient was treated by this physician from June 3, 2002, to Sept. 12, 2007. During this period, the patient continued to be noncompliant with both his medications and his low salt/low cholesterol diet, despite his cardiac risk factors. Laboratory studies from July 26, 2006, and Sept. 12, 2007, were remarkable for very elevated cholesterol and triglyceride levels. Despite this, the physician did not prescribe lipid-lowering medication, nor did he perform an EKG or refer the patient to a cardiologist for evaluation.

Concurrently, the patient was also examined by the fire department physician for “clearance physicals.” On July 26, 2006, this physician performed an EKG that revealed “NSST changes” [nonspecific ST changes]. The patient was advised to schedule a stress test “with his PCP.” However, he did not do so. Further, it was unclear whether the July 2006 EKG report was ever sent to and reviewed by the family physician. Despite knowing of the concurrent care, the physician relied solely on the patient to comply and to provide him with records or information from the fire department physician.

The family physician next saw the patient on March 14, 2008. His weight had increased to 214 pounds. His blood pressure was 130/80. The patient was advised to adhere to a low sodium and low cholesterol diet.

On June 26, 2008, the patient was seen by the fire department physician who performed an EKG. The EKG was interpreted as “borderline abnormal.” He was advised to have a stress test. His cholesterol and triglycerides levels were elevated. He was advised to follow-up with his family physician. However, he again failed to comply with this advice. Additionally, his family physician failed to obtain records from the fire department physician despite being well aware that he too treated the patient.

On April 29, 2009, the patient returned to the family physician for a check-up. Due to his complaints of erectile dysfunction, the family physician discontinued the ACE inhibitors, placed him on Benicar and recommended that he return to the office in 4-5 months. At that time, he also recommended that the patient undergo a complete physical examination. However, he did not put the patient on cholesterol and triglyceride lowering medications because the patient was resistant to taking them.

On July 29, 2009, the patient presented to the emergency room with complaints of being lightheaded. Importantly, he denied chest pain or shortness of breath. His EKG identified non-specific ST abnormalities. He was discharged with instructions to rest and follow-up with both his family physician and a cardiologist. The patient called the family physician and advised him of both the hospital visit and the test results. The physician referred him to a cardiologist to undergo a stress test. However, later that same evening, the patient was brought by ambulance to the hospital complaining of severe chest pain and shortness of breath. While being monitored, he suffered a cardiac arrest and expired on July 30, 2009. He left a wife and two teenage sons.

The Lawsuit

The patient’s estate commenced a lawsuit against both the family physician and the emergency department physician. The allegations against the family physician included negligent failure to obtain routine cardiac workups, the failure to prescribe medications to lower the patient’s markedly elevated cholesterol and triglycerides and the failure to address an abnormal EKG performed by the fire department physician.

The case was reviewed by multiple experts. They opined that the family physician should have performed complete annual physical examinations, including periodic EKGs and laboratory tests to evaluate his lipids. Further, he should have promptly admitted the patient to the hospital when he was called on July 29, 2009. Instead, over the years, he had relied on the fact that the patient informed him that the fire department physician would be obtaining EKGs. However, the family physician had continuously failed to obtain any records from either the fire department physician or even the patient’s prior treating physician.

When questioned by defense counsel, the family physician admitted that he should have been more diligent in addressing the patient’s potential cardiac issues. He stated that he had failed to do so because the patient was not only a family friend but had performed building repairs for him. Ironically, the plaintiff’s attorney was a friend of both the plaintiff and the defendant family physician. Further, all their children were friends as well.

The litigation was settled on behalf of the family physician and the codefendant emergency room physician settled with the estate later.

Legal Landscape

This case epitomizes what can go wrong when treating a friend, relative or even an acquaintance. In this case, the documentation was not only insufficient, but at times did not exist. The failure to obtain the final report of a test that was ordered and the failure to follow up and use a tickler system resulted in serious delays in diagnosis, which were both devastating and life threatening.

You must always perform a thorough history and examination. It is important to listen carefully and respond to the patient’s concerns and questions, just as you would with any patient. The patient’s needs and wishes must be both identified and respected. From the patient’s perspective, they may not be open or comfortable, or may even be embarrassed, discussing certain information with you that could potentially be crucial to diagnosis and treatment. You may fail to ask crucial questions while taking a history. The patient may feel pressured or unable to question you about a proposed treatment or symptom. Taking a complete history and performing a thorough physical examination requires that you ask all the same questions and perform the same examination that you would for a patient who is not a relative or friend.

When appropriate, make referrals to specialists or consultants. If the patient’s condition is potentially serious, you should make the appointment with the specialist or consultant. Follow up of all tests and referrals to consultants must be as aggressive as with any other patient.

You should use a tickler system to track whether the tests have been performed or the consultations obtained. If the patient has not complied, you must make a telephone call to that patient. If there is no response, you must send a letter to urge the patient to comply with your recommended treatment plan.

Your care must always remain reasonable, appropriate and consistent with the standard of care that you provide to all your patients. If the patient at any time indicates they feel pressured by you regarding the choice of treatment or they pressure you to perform procedures which are beyond your skills, competency and expertise, you should respectfully decline to continue to treat that patient. When this occurs, promptly refer the patient to the local medical society or their insurance carrier to obtain the name of a competent professional or specialist. You must not succumb to patient pressure to provide treatment and care beyond your skills and training.

In summary, if you decide to provide treatment to friends or relatives, you must be careful to treat them exactly as you would all your patients. Do not fear to upset a patient who is a friend or relative by adhering to the standard of care you must provide. Your failure to do so may come back to haunt you in the future.

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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.