Physicians are multitaskers. Every day, we balance the demands of patient care, the burden of regulatory mandates, and the needs of our families—and try to get adequate rest and recreation in the process!
As pressures upon us increase, we have begun to build teams and systems that ensure the kind of care our patients demand. We may not be able to deliver personal continuity to every patient, but a team can approximate that continuity—after it meets several key challenges. Foremost: developing systems of communication that are consistent, reliable, accurate, and accessible to any member of the team.
There is another locus in the continuum of care that is often neglected: post-event follow-up for medical, psychosocial, or legal purposes. The following case illustrates this point.
C.S., a 34-year-old G4P3, at 35 weeks’ gestation with suspected premature rupture of membranes, was referred to the tertiary-care center where I practice. She had reported a gush of fluid, and the referring physician had observed nitrazine-positive fluid at the introitus.
On initial speculum examination at the tertiary-care center, no fluid was observed coming from the cervix, and vaginal secretions were nitrazine-negative. The cervix was long, posterior, and patulous. Ultrasonographic examination of the uterus demonstrated a normal fetus of appropriate size for the reported gestational age and a maximum pocket of amniotic fluid greater than 10 cm in depth. The fetus was active, and the nonstress test was reactive. The patient’s urine was alkaline; a specimen sent for culture was found to be negative.
Despite the reassuring clinical assessment, this mature multipara’s description of events was credible. She was offered the option of overnight observation or amniocentesis with instillation of indigo carmine. Because her husband and 3 children would have had to stay in their car overnight if she remained in the hospital, the patient chose instillation.
Amniocentesis was performed under sonographic guidance, with a return of clear fluid. The fluid was sent to the lab for fetal lung maturity testing, which was negative. Ten cubic centimeters of indigo carmine dye were instilled, and a tampon was inserted. After 2 hours of ambulation, there was no dye on the tampon, and another nonstress test was reactive. The patient was discharged.
The next day, the patient reported to her family physician complaining of severe uterine pain, fever, and a loss of fetal movement. When fetal heart activity could not be detected by Doppler ultrasound, she was again referred to the tertiary-care center. There she was noted to be in extreme pain, with a temperature of 104°F, and bulging forewaters. There was copious fluid and no fetal heart motion on ultrasonography.
Amniotomy elicited a gush of clear, blue, odorless fluid. The cervix dilated completely, and the fetal head was expelled to the chin. Examination revealed a nuchal and shoulder cord tightly wrapped and tethering descent. The vaginal wall was retracted, and the cord was visualized and divided. A stillborn male was immediately expelled, and the placenta followed rapidly. Bleeding remained within normal limits.
Although there was no explanation for the fever, the patient was treated with antibiotics during her postpartum hospital stay. She recovered quickly. Cultures from mother, baby, and placenta detected no organisms. The patient was discharged on day 4.
Ten months later, the patient filed a lawsuit alleging a failure to diagnose amnionitis at the time of the first visit.
What prompted the lawsuit?
Clearly, this patient had a tragic loss. Just as clearly, there were multiple incongruities between her clinical presentation and the outcome. The patient and the care team were both aware of these truths.
Research has demonstrated that physicians who interact in a positive manner with their patients are less likely to be sued than those who fail to communicate warmth and caring. Patients of physicians who have a history of multiple lawsuits may consider them knowledgeable and competent—but they also are likely to describe them as unavailable, abrupt, and disinterested. Patients often characterize their experiences with such physicians as negative even when the clinical outcome is good. This negativity often prevails even when the office staff is skilled in communication, education, and support.1,2