News: An 18-year-old woman underwent hospital testing to determine if there were physiological causes of her psychosis. The patient was examined by several clinicians, including a psychiatrist, but the physicians did not act on abnormal test results indicating lupus. The patient received treatment after a second hospitalization at a different location, but died of organ failure from the untimely diagnosis.
The patient’s family filed a malpractice suit against multiple care providers, including the psychiatrist. The psychiatrist filed a motion to dismiss, which was granted based on alleged deficiencies with the patient’s family’s expert. However, the dismissal was reversed on appeal after the court found the expert sufficiently qualified.
Background: In December 2018, an 18-year-old woman sought treatment for psychosis. Providers were attempting to determine whether the psychosis was the result of physiological causes. Several physicians examined and treated the patient, including a psychiatrist. Before the psychiatrist’s examination, a nurse practitioner noted the patient’s father described a family history of lupus and suggested she be evaluated for the disease.
The psychiatrist treated the patient five days after her admission, and four days before the patient was discharged. The psychiatrist allegedly viewed the chart three days after discharge but did not act on it. The patient’s test results indicated lupus, but none of the physicians recorded a potential for lupus or referred her for a lupus evaluation.
The patient subsequently sought treatment at a different hospital where she immediately started treatment for lupus. However, the patient’s condition had significantly deteriorated by that time. The patient died of organ failure because of lupus.
The patient’s family filed a malpractice action against multiple care providers, including the initial psychiatrist, alleging the psychiatrist’s failure to diagnose and ensure timely treatment of the patient’s lupus caused her death. The defendant psychiatrist initially challenged the action based on the patient’s supporting expert’s qualifications. The defendant argued the patient’s expert lacked the same knowledge or experience in the same specialty or practice as the defendant because the expert was a rheumatologist and not a psychiatrist. The defendant additionally raised the patient received care from multiple other physicians at the hospital, and even sought care outside the hospital; the psychiatrist was nominally involved.
The plaintiff’s expert stated he had routinely diagnosed and treated many patients with autoimmune diseases, including lupus, and explained lupus is more prevalent and severe in young women, particularly in the minority population to which the patient belonged. Furthermore, the expert opined psychosis is a classic sign of lupus, and it can be ruled out by certain antibody tests. The rheumatologist claimed many different specialties of physicians are required to recognize signs and symptoms for lupus, including psychiatrists.
The trial court agreed with the defendant physician, stating that although the rheumatologist expert was qualified in diagnosis and treatment of autoimmune disorders, the expert did not have specialized knowledge of the standards of care for psychiatrists. An appellate court reversed the lower court. The appellate court ruled a medical malpractice plaintiff’s expert does not have to possess knowledge and experience in the same specialty or practice as the defendant care provider. Rather, what is required is the expert is knowledgeable and experienced in the practice or specialty relevant to the acts or omissions the plaintiff alleges constitutes malpractice.
What this means to you: Before considering the legal aspects of this case, a healthcare professional should be aware the diagnostic test results revealed the presence of an autoimmune disorder that can manifest itself as acute psychosis. But that information, present in the medical record, was either not noticed by the practitioner who appropriately ordered the diagnostic tests — a clearly negligent act of omission — or not recognized by the practitioners who reviewed the test results as indicative of an autoimmune disease that can present as an acute psychosis. Finally, no consideration was given to the fact the patient fit the demographic of those individuals most commonly afflicted with this disorder.
From the legal perspective, this case highlights the importance of experts for medical malpractice litigation and finding the right expert. Since the practice of medicine is a highly skilled and highly specialized field, it is critical for an expert to possess the requisite skill, knowledge, and experience to persuasively comment on pertinent issues. In this case, the critical malpractice was related to the failure to diagnose and treat lupus, an autoimmune disease that can be difficult to diagnose based on symptoms that mirror other conditions. There are common symptoms, though, and other factors increase the risk of lupus.
As the rheumatologist expert noted, the patient’s age, gender, race, family history, psychosis, and pancytopenia were all factors that when viewed in the totality of the information available, strongly indicated lupus. Lupus is more common in women between ages 15 to 45 years, and in African Americans, Hispanics, and Asian Americans. Furthermore, the expert noted lupus can be ruled out by antinuclear antibody and anti-double stranded DNA (anti-dsDNA) tests because an elevated anti-dsDNA finding is essentially conclusive of lupus. The expert’s comments reveal a critical lesson from this matter: Evaluating a patient’s full medical history, inquiring about family history, and considering the totality of the information available is an important aspect of diagnosis, and the failure to do so may constitute malpractice. Physicians and care providers should prepare thorough questions and carefully consider the responses from patients as part of the diagnostic process. It does not appear the care providers failed to ask the questions, but instead failed to act on the responses to those questions.
Typically for malpractice actions, the parties seek and retain experts in parallel fields as the care providers. It is unusual here because the defendant physician was a psychiatrist, yet the expert was a rheumatologist. This unusual circumstance led the defendant care provider to challenge the propriety of the rheumatologist as an expert. The trial court initially agreed, finding the expert was qualified in opining on the diagnosis and treatment of autoimmune disorders, including lupus, but the expert did not practice as a psychiatrist or possess specialized knowledge of the standards of psychiatrists.
The appellate court disagreed. Because the issue was diagnosis and treatment of lupus, the expert was not required to practice as a psychiatrist to comment on the diagnosis and treatment of lupus. The expert noted a multitude of physicians should understand the classification and criteria for lupus, including primary care physicians, hematologists, psychiatrists, and family practice physicians, among other specialists.
In a malpractice action, retaining the right expert to opine about standards of care is critically important for care providers. An unbelievable expert, or the wrong expert, can be fatal for a care provider’s defense. Similarly, evaluating and challenging an opposing party’s expert may be a viable defensive strategy. Here, the difference between a psychiatrist and a rheumatologist was apparent and initially was a successful challenge to the opposing expert’s propriety.
A final lesson from this case is the use of appeals. While the appeal in this matter quashed the defendant care provider’s initial success, the opposite easily could have occurred whereby the defendant’s expert was challenged and improperly excluded by a trial court. Judges are human and make erroneous decisions, whether on the law itself or on applying the law to the specific facts. In this matter, the plaintiff successfully appealed the erroneous determination by the trial court and maintained the possibility of liability for the defendant psychiatrist. When faced with an erroneous determination by a court, providers should carefully consult with counsel to determine the best manner of appealing and challenging such a decision.
REFERENCE
- Decided May 19, 2022, in the Court of Appeals of Georgia, First Division, Case Number A22A0378.
From the legal perspective, this case highlights the importance of experts for medical malpractice litigation and finding the right expert. Since the practice of medicine is a highly skilled and highly specialized field, it is critical for an expert to possess the requisite skill, knowledge, and experience to persuasively comment on pertinent issues.
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