David M. Lang offers insight on treating "knowledgeable patients."
Cases reprinted with permission from Medical Malpractice Verdicts, Settlements and Experts, Lewis Laska, Editor, (800) 298-6288.
Did Pediatrician Give Informed Consent?
A California pediatrician, age 66, presented to the defendant pulmonologist in May 2008 with asthma-related complaints. He was advised to self-administer a test for tuberculosis, which yielded positive results. In August, the pulmonologist made a diagnosis of latent tuberculosis. After undergoing liver function studies with normal results, patient was prescribed isoniazid.
In November, the patient started to develop fatigue and other symptoms. In December, he was diagnosed with overt jaundice, for which he was treated. He did not return to work for six weeks and he claimed that he did not return to full strength until April 2009.
The plaintiff alleged negligent treatment and failure to provide informed consent. The plaintiff further claimed that the defendant had not warned him about the risks associated with isoniazid and that he was never told to come back for follow-up evaluation or to undergo repeat liver function studies.
The defendant claimed that informed consent was obtained and that the plaintiff was aware of the risks of taking the drug, as he was also a licensed pharmacist and had prescribed isoniazid to patients himself. The defendant maintained that the plaintiff was told to return for liver function studies and follow-up. The defendant also claimed that the plaintiff had delayed in reporting symptoms.
According to a published account, a defense verdict was returned.
This case raises the issue of pitfalls in managing a medically knowledgeable patient. We have all treated health professionals. Sometimes these are pleasurable experiences, sometimes less so. However, irrespective of the patient’s background, it is important that we do not shortchange our professional patients.
Clinicians treating a medically knowledgeable patient may be concerned about insulting the patient by insisting on formalities and explaining matters in the usual manner. In this case, while there was dispute over whether follow-up liver function tests were recommended, the pediatrician/patient claimed that he had not given informed consent for treatment with isoniazid. To prevail on a claim of lack of informed consent in California, the plaintiff must show that a prudent person in the plaintiff’s position would have declined the intervention if adequately informed of the risks. The plaintiff here, a licensed pediatrician, claimed that he was not aware of the risks associated with isoniazid, and that he would not have consented to treatment if he had been informed of the risk for hepatotoxicity.
Therefore, when treating a medically knowledgeable patient, take nothing for granted. Conduct the visit as you would for any other patient. Obtain vital signs, chart identically, and inform fully. I have often found it helpful to stick to my usual routine, while sprinkling the visit with “as you know” or “as you may know” to show respect for your patient’s knowledge, while at the same time covering all essential aspects of the visit. —DML