It's a common scenario: A primary care physician refers his or her patient to a specialist for an acute condition. The specialist works up the patient and prescribes medication, for which the primary care physician is expected to issue refills. Who is responsible for monitoring the medication?
A middle-aged truck driver had been seeing Dr PC, a primary care physician, for a number of years for sleep apnea, breathing problems, high cholesterol, and high blood pressure. Dr PC had the patient undergo intermittent thyroid panels because of weight concerns, and the results over several years were within normal limits. But when the patient requested a thyroid panel at a visit 3 years on, Dr PC noticed her patient was tachycardic. An ECG revealed atrial fibrillation, and the patient was wheeled to the hospital across the parking lot.
At the hospital, the patient's cardiologists diagnosed hypertrophic cardiomyopathy, and he was discharged 4 days later with prescriptions for amiodarone 200 mg twice daily, as well as carvedilol, digoxin, furosemide, and warfarin. The patient's thyroid-stimulating hormone (TSH) test was within normal limits on discharge.
The patient saw his cardiologist, Dr C, the next week and several times further that year. He also continued to see Dr PC, who in fact sought Dr C's clearance before the patient's surgery for a shoulder injury. Dr C wrote to Dr PC and thanked her for the referral, described the patient's cardiac condition, and declared him to be at low to medium risk for the surgery. Dr C advised Dr PC that the patient "should stop his warfarin prior to the surgery and restart it when you feel he is safe postoperatively."
At a visit to Dr C later that year, the patient said that he had gained weight, tired easily, and had difficulty breathing on exertion. His heart rate was 50 beats/min, and his blood pressure was 90/58 mm Hg. Dr C ordered echocardiography, chest radiography, and CT angiography. Dr C decreased the patient's amiodarone bedtime dose to one half-tablet.
The echocardiogram obtained 2 weeks later suggested hypertrophic cardiomyopathy.
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However, 3 weeks later (and before getting CT), the patient was found unconscious by his neighbors. He received amiodarone from the emergency medical technician and again at the emergency department.
Lab work at the hospital revealed a TSH of 121.32—an elevated value that was commented on by two consulting cardiologists and an endocrinologist. One cardiologist noted that hypothyroidism appeared to play a significant role in the patient's bradycardic disorder. The patient was discharged 3 weeks later for rehabilitation and sued Dr PC and Dr C for medical negligence. Neither had tested the patient's thyroid hormone levels during his course on amiodarone.
During the litigation, the plaintiff's attorney presented a declaration by an expert internist stating that as the patient's primary care physician, Dr PC had a duty to know the potential side effects of her patient's medications. According to the declaration, Dr PC had a duty to order a thyroid function test while the patient was on amiodarone or to communicate with Dr C on whether he had ordered a recent thyroid screening test.
Another declaration, by a cardiologist, concluded that had either Dr PC or Dr C ordered a TSH screening test during their treatment of the patient, the patient's hypothyroidism would have been diagnosed and the cardiac event avoided. The litigation was resolved informally before trial.
The risk management lesson here is not whether the cardiologist or the primary care physician had primary responsibility to monitor the medication. Rather, communication with each other as to who would take on that responsibility would have provided the win-win solution for all involved.
This case comes from the "Case of the Month" column featured in the member newsletter published by the Cooperative of American Physicians, Inc. The article was originally titled "When the Specialist and the PCP Need to Have 'The Talk.'"
© 2020 Cooperative of American Physicians, Inc.
This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.
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