Physician Connection Survey — Page 4 Families and Individuals More Likely to Get Certain Diseases, Such As Cancer, Diabetes Or Alzheimer’S Disease

PROFESSIONAL SOLUTIONS INSURANCE COMPANY BRINGS YOU PRACTICAL TIPS FOR AVOIDING A MALPRACTICE ALLEGATION ISSUE 4 • 2011

INSIDE THIS ISSUE:

> Why the Patient History Why the Patient Is So Important — Page 2 > Family History: Practical History Is So Important Considerations — Page 3 > Recap of Physician Connection Survey — Page 4 families and individuals more likely to get certain diseases, such as cancer, diabetes or Alzheimer’s disease. More and more genetic markers are The PCP then advised the patient to being identified. It is exciting and call him if the symptoms increased in profound that physicians may be able to severity or occurred more frequently. offer at-risk patients the opportunity for The physician told the patient to return individualized testing and treatment to for a follow-up appointment in six “The medical interview or consultation actually prevent disease. However, this weeks. Within 12 hours, however, the influences the precision of diagnosis ability will be contingent upon obtaining patient suffered a massive MI and died and treatment, and studies have a detailed history. Consider the following before the ambulance arrived. indicated that over 80 percent of scenarios: The patient’s family brought suit diagnoses in general medical clinics against the physician for wrongful death are based on the medical history.” Scenario 1: Family History of of the patient. The key issue was that the —Epstein, Perkin, Cook, et al. Clinical Examination, Cardiac Arrest patient had a known family history of 4th Ed. (2008). Mosby, Ltd. A 45-year-old male presented to his sudden cardiac arrest. Both his father primary care provider (PCP) and paternal uncle had suffered fatal MIs In spite of all of the technology complaining of chest “tightness and before they reached the age of 50. This available today, the history is still the palpitations,” nausea and profuse history was known to the PCP and was mainstay of diagnosis. The impact of sweating of 12 hours duration. The PCP documented in the patient’s record. The social, environmental, hereditary and did a complete physical exam and EKG physician simply did not review the behavioral factors on patient well-being in the office, which were normal. The patient’s history when the patient was and illness must be realized in the PCP said he thought the patient was seen and stated he had forgotten about patient’s history. having an anxiety attack related to his the family history. Advances in the field of genetics and recent job loss and suggested the patient Discussion: The physician did not the work of the Human Genome Project take a mild antidepressant to relieve his review the patient’s history when the have made possible the identification of symptoms. However, the patient refused patient presented with symptoms genetic alterations that make some the prescription. suggestive of cardiac problems. The PCP

What to Do When a Patient suspect a patient is considering a lawsuit get a letter from an attorney, a summons Might Sue or a complaint against you before your or complaint) is to contact PSIC at The first step you should take if you state board (and certainly any time you 1-800-640-6504.

aunt called 911 and the child was alleging failure to order a mammogram A complete and accurate promptly and successfully treated with when the patient reported discovering a history is the foundation for epinephrine by emergency personnel. lump, resulting in a delayed diagnosis of all future patient care. Discussion: The FP should have taken breast cancer, metastases and untimely additional steps to determine whether death. Key to the plaintiff’s case was the the child had any medication allergies fact that the patient had a family history before prescribing penicillin. The aunt’s of Cowden Syndrome, an autosomal- did perform an EKG and, finding no vague response should not have been dominant condition known to be irregularity, assumed the symptoms were enough to jump to the conclusion that associated with several types of stress related. However, based on the penicillin could safely be given. Since malignancy, particularly with breast patient’s significant family history, the this was not a life-or-death situation, the cancer in females. This fact had been physician should have had a high index clinic physician should have taken the related to the physician at the time of the of suspicion for myocardial infarction. time necessary to contact the child’s patient’s initial appointment at age 25 Further diagnostic studies such as cardiac parents or her pediatrician’s office. and had been noted in her history. enzyme measurement were indicated. At his deposition, the physician Had the physician done so, the outcome Scenario 3: Genetic Marker admitted that he simply wasn’t familiar could have been much different. and Insurance Issues with Cowden Syndrome. The case was A 38-year-old woman was seen by her settled by the defense prior to going to Scenario 2: Possible gynecologist for a routine gynecological trial. Medication Allergies checkup. The patient mentioned to the A 4-year-old girl was being seen by a physician that she thought she noticed a family practitioner in a walk-in clinic on small lump on the upper outer quadrant The AMA’s website provides a Saturday morning with complaints of a of her right breast during her monthly information on red ﬂags that painful sore throat and difficulty breast self-examination (BSE). The could indicate a genetic swallowing. She was brought to the doctor did a thorough breast condition or inherited clinic by her aunt who was watching the examination and could not find the susceptibility to a certain child while her parents were on vacation. lump on palpation. disease. The child, her parents and her regular The patient’s health insurance did not pediatrician resided in a town four hours cover screening mammograms until the away. The aunt said the child seemed to age of 40, so the physician said he would Discussion: The family history of be feverish. The aunt had a signed form give her a referral for a mammogram at Cowden Syndrome should have alerted from the parents giving her the requisite her next visit, which was scheduled for the gynecologist to the fact that this authority to make medical decisions for two years later. The physician told the patient was at increased risk of breast the child in the parents’ absence. patient to continue BSE and to call if the cancer at an earlier age. The use of The FP diagnosed a strep infection, lump was again noticeable. genetic markers to identify patients with confirmed by a rapid strep test. The FP When the patient returned two years gene disorders or chromosomal asked the aunt if the child was allergic to later and had her first mammogram, a abnormalities is increasing. This any medications, and the aunt said, “I’m mass was found in the upper outer knowledge can be extremely valuable in not sure, but I don’t think so.” The FP quadrant of the right breast. Subsequent determining a patient’s predisposition to prescribed Penicillin V and told the aunt biopsy was positive for malignancy. The chronic diseases like diabetes, cardiac to have the patient seen by her regular patient underwent a right mastectomy disease and certain cancers. pediatrician if she wasn’t asymptomatic and was found to have 6 of 8 axillary The gynecologist’s admission that within 4 to 5 days. The aunt filled the nodes involved. Despite aggressive Cowden Syndrome was in the patient’s prescription. chemo and radiation therapy, the patient history but he wasn’t familiar with it was Unfortunately, the child had a known succumbed to her disease three years inexcusable. He was negligent in not allergy to penicillin and had an later at the age of 43. referring the patient for mammography anaphylactic reaction to the drug within The gynecologist was the target of a or other imaging studies to rule out a half hour of taking the first dose. The lawsuit brought by the patient’s husband breast malignancy. ISSUE 4 • 2011 3

Resources Family History: The Three-Generation www.ama-assn.org/resources/doc/genetics/ U.S. Surgeon General’s Family History Pedigree: D.J. Wattendorf & D.W. Hadley, ped_screening.pdf Initiative: Information about ways to collect a National Human Genome Research Institute, Pediatric Clinical Genetics Questionnaire family history and help health professionals National Institutes of Health, Bethesda, Maryland. www.ama-assn.org/resources/doc/genetics/ encourage the collection of a family history. Am Fam Physician. 2005 Aug 1; 72(3):441-448. ped_clinical_genetic.pdf www.hhs.gov/familyhistory www.aafp.org/afp/2005/0801/p441.html Harvard Vanguard Medical Associates: “My Family Health Portrait” is a web-enabled Pediatric Genetics: Use of Family History Adult Medical History Form program that helps people organize their family Information in Pediatric Primary Care and www.harvardvanguard.org/info/ history information and print it out for their Public Health. www.cdc.gov/ncbddd/ AdultMedicalHistory.pdf family doctors. People can save this information pediatricgenetics/genetics_workshop/index.html onto their own computer and share it with other Palo Alto Medical Foundation: Adult Health family members. https://familyhistory.hhs.gov/ Does It Run in the Family? A family health History for NEW Patients www.pamf.org/ history tool from Genetic Alliance. http://family forms/143952_Adult_Med_Hx.pdf Centers for Disease Control and Prevention’s healthhistory.org/ Family History Public Health Initiative. Sample forms are provided solely for general infor- www.cdc.gov/genomics/famhistory/index.htm Sample Forms mation and educational purposes. They are not offered as, nor do they constitute, legal advice or American Medical Association: Family Medical American Medical Association: opinion. Physicians should tailor their history forms History in Disease Prevention. www.ama- Adult Family History Form www.ama-assn. to their specific needs and patient populations and assn.org/ama1/pub/upload/mm/464/family_hist org/resources/doc/genetics/adult_history.pdf in consultation with an attorney. Inclusion on the ory02.pdf Pre-natal Genetic Screening Questionnaire list does not indicate any type of PSIC endorsement.

What Can We Learn? • The accuracy and completeness of the Pay particular attention to changes address any blank or “N/A” areas. information contained in a patient’s in medications and be aware that Though nurse practitioners and history is essential for optimal patient patients may be seeing other physicians physician assistants are usually well- care. A complete and accurate history is who are also prescribing medications trained and skilled in history taking, the foundation for all future patient or therapies. Drug-to-drug the physician is ultimately responsible care—whether preventive care, diagnosis interactions are a significant cause of and should regularly review the and treatment of acute or chronic patient morbidity and mortality and information gathered, especially when illness, or prescription of medication. medical malpractice actions against the patient displays a confusing There are several important points to the physician prescribers. If this is clinical presentation. • remember with the patient history: done by an intake nurse or physician Be aware that physicians are still • Ask the patient about changes or extender, any changes should be accountable for knowing the additions to the history at each visit. brought to the physician’s attention. information in the patient’s chart. These include any new or For example, the new information For example, the gynecologist in the discontinued medications, new could be highlighted on the chart, third scenario should have known conditions, new allergies, or changes verbally relayed to the physician and that Cowden Syndrome predisposed in socio- or demographic information documented in the patient’s chart. his patient to breast cancer. • (e.g., marital status, job status, health Carefully review any initial history status of a family member, or travel by physician extenders to clarify, outside of the U.S.). confirm and elicit more details to Taking the time to complete a family history is well worth the effort. Family History: Practical Considerations Reasons to Collect Family such as heart disease and diabetes. shared environments and behaviors History Information • Family history can help you make that might put a patient at higher risk. • • Family history is a traditional tool for informed decisions about screening, It helps identify inheritance patterns diagnosing and identifying risk for patient education and other and correct mistaken beliefs—for genetic disorders. It is also being used preventive health measures. instance, that a disease affects only more commonly to assess risk for • It helps physicians build rapport with one gender or skips a generation. complex common conditions for patients and their families, understand • Family history is an essential part of which the genetic cause is unknown, family relationships, and identify a complete physical exam visit.

Continued on Page 4 4 PHYSICIAN CONNECTION

Strategies for Collecting • Add family history links to the practice Questions? Family Histories in a website. Ask patients or parents of If you have any questions you’d like our minor patients to gather information Connection experts to answer, please e-mail Pediatric Practice them to [email protected] before they come for an office visit. • It is helpful to use frequent well-child • Provide handouts with resources for exams to complete and update family collecting family medical history. history information. (If a patient • Post reminders for clinicians and comes in for all recommended well- addressing any concerns helps obtain families, such as “Five minutes for child exams, the clinician will see the complete and reliable information. family history” or “Don’t forget the • patient 10 times in the first two years In the case of a minor patient, several family history.” of life.) caregivers may be involved in a child’s • Review and update family history • Several tools can help collect family healthcare. Partnering with parents every year. histories. and other caregivers will help – Find a summary of tools from the overcome this barrier. National Coalition for Health Challenges to Overcome • Adapted from the National Center on Birth Professional Education in The main barrier to collecting a Defects and Developmental Disabilities, Centers Genetics at www.nchpeg.org. complete family history is time, but for Disease Control and Prevention’s Family – making the time to capture and History: Practical Considerations for Pediatric Families can create a simple Primary Care Clinicians. pedigree with the Surgeon review this information is well worth www.cdc.gov/ncbddd/pediatricgenetics/genetics General’s “My Family Health the effort. _workshop/family_history_hcp.html. Portrait” at https://familyhistory. • Clearly explaining how family history hhs.gov/. can benefit one’s health and

Recap of Physician Connection Survey

In March and April 2011, PSIC conducted a survey about the the articles and case examples, risk management tips, and Physician Connection newsletter. Recipients were asked to rate supportive handout materials “useful” or “very useful.” and rank a number of aspects of the newsletter. The survey also Risk management topics deemed most relevant were: doc- provided an opportunity for recipients to write in specific umentation/recordkeeping, patient communication and suggestions for future topics and ways to improve the legal/regulatory news. As a result of the survey findings, PSIC newsletter. will feature these topics in more depth and also offer additional If you participated in this survey, thank you! Your comments website references. are important to us, and we want you to know we listened. If you have more feedback, please feel free to contact Responses were received from physicians, office managers, Veronica Brattstrom at 1-888-336-2642 or physician assistants, risk managers and others. Overall, the [email protected]. newsletter received high ratings: More than 80 percent rated

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