Guest Commentary | It costs about $80,000 to defend a cardiologist in a medical malpractice claim resulting in payment—nearly four times the cost in ophthalmology, the least expensive specialty to defend.¹ Even in 2015, that is a great deal of money, and it likely heightens cardiologists' motivation to do everything possible to avoid liability lawsuits, while still doing what is best for the patient. All future lawsuits cannot be avoided, but understanding the clinical circumstances of previous suits may help us minimize their prevalence and impact, while still allowing us to provide excellent healthcare.

A recent examination of closed claim data from The Doctors Company, the nation's largest physician-owned medical malpractice insurer, helps identify steps we as cardiologists can take before, during, and after patient interactions that meet the twin goals of optimizing patient care and protecting ourselves legally, particularly in the face of inevitable complications and other poor clinical outcomes.

Cardiology may hold a unique place in the medical malpractice landscape because of its diverse set of physician-patient interactions. Not only do we diagnose conditions that are often life-threatening, we also perform invasive procedures on some of the very sickest patients. The wide diversity of these cases may make this specialty a particularly good model upon which to extrapolate conclusions about the liability pitfalls facing all clinicians. Ideally, analysis of the details of 429 closed claims occurring in cardiology between 2007 and 2013 will offer insight to all physicians about the types of clinical scenarios that create the largest potential liability risks.

Topping malpractice claims is failure of diagnosis, which was alleged in 25% of closed cases. While myocardial infarctions are sometimes misdiagnosed in cardiology—and even more frequently among physicians without specialized cardiac training—the new data show cardiologists are more likely to overlook non-cardiac diagnoses that present similarly to a cardiac ailment, such as pulmonary embolism, aortic dissection, or even cancer.

Lawsuits stemming from procedural or surgical complications are the next most prevalent, which is both unsurprising and frustrating. Even the most skilled and experienced proceduralist will have complications; in an ideal world, expected complications should not, in and of themselves, trigger a lawsuit. Unfortunately, they often do.

For interventional cardiologists, lawsuits stemming from vascular access complications—retroperitoneal bleeding, in particular—represented the primary source of liability danger, with a close second being other vascular complications such as embolism or coronary artery damage.

Among electrophysiologists, three complications represented the bulk of malpractice suits: 1) arterial laceration during a pacemaker implantation or electrophysiology study, 2) atrioventricular node damage during ablation that required pacemaker placement, and 3) pulmonary vein stenosis after ablation. Transesophageal echocardiography, though not an invasive vascular procedure, had two primary liability risks—first, lawsuits after esophageal perforation, and second, neurological damage caused by neck flexion in patients with undiagnosed epidural abscess.

The data also show that prescribing certain medications should set off "liability alarm bells," since improper medication management accounts for the fifth most common allegation. For example, the significant lung and liver side effects from amiodarone can be a fertile ground for lawsuits from patients who may blame the physician years after the drug was first prescribed. Similarly, the use of warfarin often places cardiologists between a rock and a hard place. The drug's narrow therapeutic window can create liability problems for physicians who need to decrease a patient's stroke risk, but may end up causing severe bleeding.

What can this data ultimately teach us about mitigating liability risk? Cardiologists should become more aware of the most prevalent types of diagnosis or procedural errors and engage in meticulous informed consent. That same meticulous attention must be paid to documentation, workup, and follow up after a complication occurs. Failing to act expeditiously—by not ordering a CT scan to evaluate a possible retroperitoneal bleed, for instance—may turn a routine complication into a lawsuit.

Rigorous documentation is always needed, but it's particularly needed when physicians choose a high-risk, liability-prone medication. Prescribing the drug is perfectly acceptable, of course; it's simply important to inform the patient about its inherent risks and vigilantly monitor for side effects. Lastly, non-cardiac issues need to be carefully watched, particularly when following up on a possible cancer diagnosis or when prescribing non-cardiac medications.

It's notable that the top reasons for cardiology lawsuits diverge so widely, encompassing both diagnosis and procedure allegations. This suggests there is no single aspect of the practice of cardiology that is particularly liability-prone. Different types of cardiologists, both proceduralists and non-proceduralists, face different types of dangers, but the dangers are real for all of them and need to be recognized.

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References

1. Seabury S, Chandra A, Lakdawalla D, Jena A. Defense costs of medical malpractice claims. N Engl J Med. 2012; 366:1354-1356.

Commentary written by Sandeep Mangalmurti, MD, JD, who is currently a cardiologist at Bassett Heart Care Institute in Cooperstown, NY. He is a graduate of the University of Chicago Pritzker School of Medicine, as well as the Yale Law School and is also a former Lecturer of Law and Medicine at the University of Chicago Law School. He has researched, published, and lectured frequently on the topic of medical liability, including articles in the New England Journal of Medicine, JAMA-IM and the American Heart Journal. Dr. Mangalmurti is lead researcher of the American College of Cardiology Medical Liability Sub Committee.

Keywords: CardioSource WorldNews, ACC Publications

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