Analysis Questions - Chest Pain Case Study

Analysis of Clinical Assessment Questions for Chest Pain Case Study

1) Should a cardiac consultation have been requested prior to clearance for surgery, in light of the patient's weight, high cholesterol, history of hypertension, and family history of her mother and brother both having myocardial infarctions?

Analysis of the specific facts of this scenario revealed factors both in favor of and contrary to the decision not to refer the patient to a cardiologist.

Under the AHA guidelines, the patient had only minor clinical predictors for an intermediate surgical risk procedure. The family practice Physician clearly considered cardiac issues and inquired about cardiac symptoms, reviewed the ECG’s and documented his interpretation as equivocal and not clearly abnormal. Additionally, it is relevant to note that the efficacy and reliability of whole body scans and CACS is not documented.
Despite the factors above, the patient had multiple cardiac risk factors, including a strong positive family history. Although this aspect alone may not have been sufficient to warrant a referral, in combination with the patient’s obvious concern; the orthopedic surgeon’s recommendation that the cardiac issues be addressed by the primary care physician; and the existence of additional potentially relevant clinical data (the whole body scan), a more detailed evaluation from a cardiologist would have been prudent.

While the case was one that could be defended, the plaintiffs had an easy argument to make to the jury that if only the primary care physician had referred to a cardiologist or obtained stress testing based on the calcium scoring, the patient would likely have undergone angiogram and possible revascularization prior to hip replacement. Such straightforward theories can be difficult to overcome, even in conservative venues; particularly, given the unfortunate timing of the M.I.

2) Were the patient’s cardiac concerns appropriately addressed and alleviated by her family Physician?

The patient specifically raised questions about whether she needed a pre-op cardiology evaluation. When a patient expresses concern about a particular health related complication it is important to address the issue, by either explaining and documenting the reason a referral is not warranted or ensuring that the concerns are truly unwarranted by recommending a referral.

3) Was it acceptable to rule out a cardiac evaluation without actually reviewing the report of the whole body scan?

The family practice Physician never reviewed the whole body scan. When information is readily available that may impact treatment decisions it should be reviewed and evaluated. In this case, the physician may have placed less weight on the results of the whole body scan, however, it should have been reviewed, evaluated and documented as to why the results may or may not have been reliable

4) Did the family practitioner miss the cumulative picture of heart disease that the patient presented with?

In retrospect the timing of the patient’s MI and the results of the automated EKG interpretations indicating myocardial ischemia were damaging hind sight information that ultimately were used as plaintiff’s evidence demonstrating the patient would have benefited from a pre-operative cardiac consultation. While hind sight is most always 20/20, physicians should not lose sight of warning signals that may indicate a need for additional evaluation.

5) Did the patient’s “non-pay” status prejudice the physician against additional testing?

This type of bias is not easily discernible. In the particular case the patient was discharged from the primary care practice for non-payment, during her hospital course just prior to her death. Such timing issues can later be used in a manner that in accurately reflects upon the intentions of the provider. While it is perfectly acceptable to have payment policies in the office, care should be taken to avoid the potential for misunderstandings when enforcing payment policies.

Disposition of the case:

The plaintiff in this case was prepared to present evidence that suggested that the physician did not read material that was available to him and other damaging information that would have been very difficult to explain to a lay jury. As a result, the Insured requested a settlement be made on his behalf. The Case ultimately concluded with an ($800,000.00) Eight Hundred Thousand dollar settlement made on his behalf prior to trial.

Take home point:

Patient-centered care can be accomplished more effectively when there is a collaborative relationship between the primary treating physician and the subspecialist. Establishing a cooperative relationship between local family practitioners and cardiologists is beneficial to everyone involved and can aid in improving the quality of patient care as well as the exchange of highly specialized expertise.