From the moment he entered my office, I knew that he and I would have a difficult time getting along.
Dan* lived most of the time in Michigan but spent his winters in Florida, not unlike many of my patients. During our first encounter he chastised me for being late. I apologized. There had been an emergency at the hospital, I explained. One of the things I pride myself on is punctuality. I took his criticism personally.
He told me that five years earlier he’d had a myocardial infarction followed by open-heart surgery. He was not having active cardiac symptoms, but wanted to establish himself with a cardiologist while in Florida.
After an exam, which was normal, and an electrocardiogram, which showed an old anterior wall MI, I ordered an echocardiogram and stress test. He consented to the former but refused the latter, insisting that he was “fine.” I was irritated but since I was already running late, I just let it slide.
A month later, I was summoned to the ER to see him for chest pain. I asked the ER physician to do some preliminary studies, which did not suggest another MI. Dan was livid, though, that I was not there sooner. I tried to explain that I was tied up in the lab with an emergency.
“Then maybe you should get some more help!” was his response.
After a 24-hour admission ruled out another MI, he again refused a stress test, stating that he was returning up north shortly and would get it done there.
I did not see or hear from Dan until the next fall, when he presented to the ER once again, after having driven himself from Michigan to St. Petersburg in little more than one day. He was complaining of chest pain, abdominal pain, and burning. I ordered more enzymes and a new echocardiogram, which showed slightly worse left ventricular function, although his electrocardiogram was unchanged. The first two sets of enzymes were negative. He agreed to be admitted overnight.
The following morning my office paged me to call the ICU, where Dan was a patient. “He’s taken off his telemetry, walked out to the nursing station, and is demanding to see you,” a nurse told me.
“Can you ask him to stay until I get over there and see him?” I asked.
“He says he’s fine and wants to go home now. He doesn’t want to wait, and says his pains were indigestion.”
What I should have said was, “Please ask him to stay until I see him, and if he refuses, then ask him to sign out against medical advice.” However, not wanting to strain the relationship further, I consented, with instructions for him to call the office for an appointment to see me in a few days.
He would never make the phone call, because as soon as he got home, he had severe chest pain. He called 911 but by the time the ambulance arrived, he was hypotensive and ashen. He coded twice en route to the hospital. The ER doctor called me, and I rushed over to help out with the resuscitative effort. Despite an hour of CPR, Dan died.
Six months later, I was served with malpractice papers by Dan’s estate.
After 18 months of depositions, expert testimony, and legal posturing, a court date was set and I prepared to go to trial.
The estate was asking for the limits of my policy: $250,000. Without my knowledge or consent my insurance company settled on my behalf for $100,000. In the end, I learned some valuable lessons.
First, there will inevitably be patients you can’t seem to please, no matter what you do or say. In these cases, you can choose to plod along, or simply discharge the patient. In Dan’s case, I would have been better off recognizing the early warning signs and asking him to seek another cardiologist for his care.
Second, due to my overly busy schedule and fatigue, I forgot to order his old records, which would have shown a post-bypass cath and graft failure.
Last, I let his impatience and demanding personality trump my clinical judgment. Since then, no matter how insistent a patient becomes, I am totally comfortable in disagreeing with his decision; and if I feel at all that a hospital discharge is potentially dangerous, I politely ask him to sign out against medical advice.
Would the outcome have changed had I handled things differently? Would Dan still be alive? Would I have been sued for malpractice? I’ll never know. However, Dan taught me to become my patients’ best advocate, even when they do not have their own best interests in mind.
* Name has been changed.
David Mokotoff has been practicing cardiology since 1982 in St. Petersburg, Fla., where he formed the Bay Area Heart Center, which today has 13 physicians in three locations. He now is semiretired from practice to pursue a writing career.
This article originally appeared in the March 2009 issue of Physicians Practice.
