The Importance of Protocols

for Dealing
with Noncompliant Patients
 Case Review from

MLMIC
Medical Liability and Mutual Insurance Company
Outpatient Clinic
BRAD
 Timeline of Events

41 yo Male Pt
First Visit

 Outpatient Clinic
o CC:
 Complaining of occasional fatigue
o Meds:
 Lithium & Tegretol
(prescribed by a psychiatrist)
 Refused to discuss specifics
 Refused to provide internist with
name of psychiatrist
o Exam:
 Slight heart murmur
o Labs:
 Elevated Cholesterol: 234
 Creatinine: 1.5
o Plan:
 Call patient, want him to return every 3
months to follow his hypercholesterolemia
 Timeline of Events
Second Visit 3 Months Later
First Visit

o CC:
 Occasional slight chest discomfort
 SOB
 RUQ abdominal pain
o Vitals:
 BP: 130/80
o Exam:
 1/6 mitral valve murmur
 Lungs clear
 Abdominal and Neuro exams WNL
o Imaging:
 Abdominal U/S
 Slight hepatosplenomegaly
o Labs:
 LFTs: Normal
 Cholesterol: 243
o Follow-up in 3 months
 Timeline of Events

7 Months Later
Third Visit
Second Visit
First Visit

o CC:
 Occasional slight chest discomfort
 SOB
 RUQ abdominal pain
o Vitals:
 BP: 130/80
o Exam:
 1/6 mitral valve murmur
 Lungs clear
 Abdominal and Neuro exams WNL
o Imaging:
 Abdominal U/S
 Slight hepatosplenomegaly
o Labs:
 LFTs: Normal
 Cholesterol: 243
o Follow-up in 3 months
 Timeline of Events

10 Months Later

Fourth Visit
Third Visit
Second Visit
First Visit

o CC: Cough and congestion

o Vitals:
 BP was 130/78
o Exam:
 Occasional rhonchi
 Normal abdominal and neuro exams

o Diagnosed with Bronchitis

o Pt refused to undergo blood tests due to

his illness
 Rx for Biaxin mg # 20 and Robitussin
AC
 Told the Pt to contact him if bronchitis
did not improve
 Internist would order X-ray
 Timeline of Events

14 Months Later

Fifth Visit
Fourth Visit
Second Visit

Third Visit
First Visit

o CC: Occasional SOB, 3-day-history of burning with

urination
 Hx: no smoking, no ETOH
o Vitals:
 120/80, normal sinus rhythm
o Exam:
 1/6 murmur
 Lungs were clear
 Remainder of exam was normal
o Labs:
 Urinalysis
 White cells
 Creatinine now 1.8
 Urine Protein was 30

o Diagnosed UTI
 Rx for Cipro BID
 Planned to perform echo and EKG at next visit
 Timeline of Events

16 Months Later

Sixth Visit
Fifth Visit
Second Visit

Fourth Visit
Third Visit

o
First Visit

CC:
 SOB
 Cough
o Noted hx of mild mitral resurge
o Vitals:
 BP 130/78, Normal Sinus Rhythm
o Exam
 Grade 1/6 murmur
 Lungs clear
 Abdomen, extremities, neuro exam
WNL
o Imaging:
 Echo color flow Doppler
 Left atrium mildly dilated
 Left ventricle slightly enlarged
o Labs:
 Creatinine now 2.57
 BUN was 42

o Given the name of a nephrologist and told

to obtain immediate nephrology consultation
 Timeline of Events

Nephrologist

Sixth Visit
Fifth Visit
Second Visit

Fourth Visit
Third Visit
First Visit

Pt was seen by a Nephrologist

 Nephrologist sent a letter to the

internist
o Documented that the pt had
bipolar disorder with a long history
of Lithium use

 Nephrologist contacted patient’s

psychiatrist to immediately
discontinue Lithium
 Timeline of Events

1 Month Later

Renal Biopsy
Nephrology
Sixth Visit
Fifth Visit
Second Visit

Fourth Visit
Third Visit
First Visit

 Patient underwent a kidney

biopsy
o Dx:
 Chronic tubulointersitial
disease
 Accompanying focal
segmental
glomerulosclerosis and
hyalinosis
 Findings consistent with
Lithium Toxicity
o Result:
 Pt was placed on the
waiting list for a kidney
transplant
 Patient filed a lawsuit against the
Internist
 Alleging:

o Internist failed to properly and timely diagnose

patient’s rising creatinine levels

o Failed to repeat elevated tests or refer him to a

nephrologist much earlier for consultation

o Failed to regularly monitor his lithium levels

Patient also filed suit against his psychiatrist

 Internist’s Deposition
 Internist testified that when he saw the patient’s
creatinine was 1.8, he promptly called the patient to tell
him to return in 3 months to repeat his creatinine test
o This call was NOT documented

 Even though the patient did not return in 3 months as

requested
o NO documentation of any follow-up efforts for a
17-month period

 Internist claimed the patient told him his psychiatrist

was monitoring his Lithium and Tegretol levels

 Testified that he was very concerned with the patient’s

elevated cholesterol and repeatedly advised him to
return every 3 months for follow-up at every visit
o Later admitted that he never informed the patient
that lithium can cause kidney damage
o Admitted he did not make any other effort to
identify or contact patient’s psychiatrist
 Patient’s Deposition
 Never told internist that his psychiatrist was following his lithium
and creatine levels

 Testified that the internist volunteered to follow Li and Cr

 Co-defendant Psychiatrist confirmed the patient’s testimony

Litigation
 Internist signed consent to settle lawsuit

 Psychiatrist refused to participate in settlement

 Patient made an unreasonable demand for damages, forcing

counsel for the internist to proceed to trial

 Prior to jury rendering a verdict, lawsuit was settles for 1.7 million
o $1,000,000 paid on behalf of the internist
o $700,000 paid by the psychiatrist
BRAD
 First Visit

Second Visit

Third Visit

Fourth Visit

Fifth Visit
Occurred?

Sixth Visit

Nephrology
Where Could Have Intervention

Renal Biopsy
 First Visit

Second Visit

Third Visit

Fourth Visit

Fifth Visit
Occurred?

Sixth Visit

Nephrology
Where Could Have Intervention

Renal Biopsy
 First Visit

Second Visit

Third Visit

Fourth Visit

Fifth Visit
Occurred?

Sixth Visit

Nephrology
Where Could Have Intervention

Renal Biopsy
 First Visit

Second Visit

Third Visit

Fourth Visit

Fifth Visit
Occurred?

Sixth Visit

Nephrology
Where Could Have Intervention

Renal Biopsy
 First Visit

Second Visit

Third Visit

Fourth Visit

Fifth Visit
Occurred?

Sixth Visit

Nephrology
Where Could Have Intervention

Renal Biopsy
 Where Could Have Intervention Occurred?
Refusal to let internist coordinate with his psychiatrist

o Should not have assumed the psychiatrist was monitoring Li and Cr level

o Once internist regularly ordered these tests, it was his duty to respond to them

o Early evidence of increasing Cr levels should have prompted the internist to discuss
the relationship between Li and potential kidney damage and insist he should be
able to communicate with patients psychiatrist

 Consider having patient sign an informed refusal form or sent the patient a letter
documenting his refusal

Renal Biopsy
Sixth Visit
Fourth Visit
Third Visit
Second Visit

Nephrology
Fifth Visit
First Visit
 Where Could Have Intervention Occurred?

 Internists sole focus on the patient’s rising

cholesterol

o Problematic in court to explain why the internist

not only failed to respond to all abnormal values
but also his rationale for doing so

Renal Biopsy
Sixth Visit
Fourth Visit
Third Visit

Fifth Visit

Nephrology
Second Visit
First Visit
 Where Could Have Intervention Occurred?
o Sending a letter warning the patient of the need to be
 Patient’s noncompliance with seen within a defined period or discharge might result
follow-up
o If patient continues to be noncompliant, he should be
o Strongly recommend making at discharged with a warning in the discharge letter that his
least one telephone call to the condition requires prompt follow-up by another physician.
patient

Renal Biopsy
Sixth Visit
Fourth Visit
Third Visit

Fifth Visit

Nephrology
Second Visit
First Visit
 Where Could Have Intervention Occurred?
 Giving the patient the name and number
of a nephrologist instead of calling the
nephrologist himself

o Fortunate the patient, with hx of

noncompliance, saw the
nephrologist in a timely manner

Renal Biopsy
Sixth Visit
Fourth Visit
Third Visit

Fifth Visit

Nephrology
Second Visit
First Visit
 Teaching Points:
 Dangerous to assume that another physician who
also treats a patient has assumed responsibility for,
and advised the patient of, the results of any
abnormal laboratory values or other tests
 Teaching Points:
 Dangerous to assume that another physician who
also treats a patient has assumed responsibility for,
and advised the patient of, the results of any
abnormal laboratory values or other tests

 Highly risky to assume that a patient has been

properly warned about the risks and side effects of
his medications
 Teaching Points:
 Dangerous to assume that another physician who
also treats a patient has assumed responsibility for,
and advised the patient of, the results of any
abnormal laboratory values or other tests

 Highly risky to assume that a patient has been

properly warned about the risks and side effects of
his medications

 When a PCP receives an abnormal test of any type,

even though a consultant or specialist also receives
the result, it is still the obligation of the primary care
physician to inform the patient of the abnormal test
result and appropriately refer the patient for follow-up
END