Risk Management



Failure to Diagnose an Occipital Aneurysm

Digest, Spring, 1994

Allegation

Insured ophthalmologist allegedly failed to diagnose an occipital aneurysm. Additionally, there were allegations of failure to diagnose and treat plaintiff’s headache disorder, which resulted in a left hemisensory deficit.

Disposition

Dismissed.


Background

Sometimes the initial discovery phase of a lawsuit can be the most productive. When the facts are clear and the evidence is persuasive, a plaintiff often can be educated in the pathophysiology of the case and dissuaded from pursuing a suit that has little chance of success. The following case is an example of how the OMIC defense team worked with the plaintiff’s attorney to obtain a dismissal.


Case Summary

The patient was a 79-year-old woman who had been a patient of the insured for four years. She was examined for complaints of difficulty with night vision, frontal headaches and URI. The decreased night vision was consistent with the previously diagnosed cataract formation in the eye. There was no mention of double vision and the pupils were equal and reactive to light. An extraocular exam was normal. The optic nerve was examined stereoscopically, and no papilledema was found. A visual field exam was not performed. A prescription change was made in the patient’s glasses and the patient left the office.

Two months later, the patient suffered a stroke due to an occipital aneurysm. She claimed that the insured ophthalmologist was negligent in failing to order a CT scan to evaluate her headaches at her previous visit.


Outcome

When the medical experts reviewed this case, they were able to defend the insured because he had carefully documented the office exam as well as the history presented by the patient. Each expert who reviewed the case came to the same conclusion: there was no indication to order a CT scan for this patient.

These reviews enabled defense counsel to discuss the case frankly with the plaintiff attorney and convince the attorney that the insured was not an appropriate defendant in this case. The plaintiff attorney persuaded her client to dismiss the case against the insured ophthalmologist based largely on the clearly written notes in the office record, which correlated with the standard of care as stated by defense experts. It was later discovered that the plaintiff attorney was unable to find an expert witness who would testify against the insured based on the facts in the record.


Risk Management Principlesand Commentary

In this age of managed care and cost cutting, physicians frequently may have to decide whether the diagnostic value of a given test justifies its cost. Medical tests always will be essential to accurate diagnosis. The guideline for whether they are indicated must continue to be based on sound medical judgment, even in the face of budget cuts and increasing pressure to keep costs down. Not every test may be needed to make a diagnosis, but if a diagnosis is missed because a necessary test was omitted, the cost of the test will not provide a convincing defense.

At times it may seem a precarious balance between the cost of additional testing and the benefit of the test to the patient. Medically sound decisions supported by clear and proper documentation provide the best defense if a claim is filed. Ultimately, one hopes the goals of physicians and utilization reviewers will coincide: to provide safe, competent and cost-effective patient care.

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Six reasons OMIC is the best choice for ophthalmologists in America.

#3. Best at defending claims.

An ophthalmologist pays nearly half a million dollars in premiums over the course of a career. Premium paid is directly related to your carrier’s claims experience. OMIC has a higher win rate taking tough cases to trial, full consent to settle (no hammer) clause, and access to the best experts. OMIC pays 25% less per claim than other carriers. As a result, OMIC’s base rates have consistently averaged approximately 15% lower than multispecialty carriers in the U.S.

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