[HKU Medical Grand Rounds] What all clinicians dread
This case scenario was presented at a grand round in the Department of Medicine, The University of Hong Kong. Unlike traditional grand rounds that directly or indirectly deal with clinical challenges posed by patients, this one was equally about doctors and how they care for their charges. All doctors who tend patients dread being implicated on the receiving end of medico-legal proceedings. This topic is therefore intimately linked to the professionalism of doctors, their standing in the community, and the ethical aspects of how they interact with patients and relatives.
Case history and subsequent developments
Ms. X was a 35-year-old single sales executive who was granted Legal Aid for her medical grievance. In June 2008, she noticed onset of fatigue, loss of energy, dry yellowish skin, and hair loss. After a body check at a private medical centre, she received a doctor-signed report stating: Physical examination, lung function test results and ECG all normal but mildly abnormal blood test results. (Table) She received a printout of all her test results, underwent liver and gall-bladder ultrasonography (no significant findings noted, with subsequent hepatitis B serology also negative), and was advised to consult other doctors for her abnormal blood results. In August 2008, she consulted a specialist (Dr. Y) with a copy of the medical centre’s report and her GP’s referral letter. That letter stated that she had malaise as well as abnormal liver function test (LFT) results and cholesterol values.
Dr. Y’s record about Ms. X did not mention any complaints or physical examination findings (not even heart rate or blood pressure), though Ms. X was adamant she had recounted them all. Nor were there any entries about Ms. X’s weight or appetite, menstrual history, or alcohol and/or drug use, whereas her father having hypercholesterolaemia was noted. Dr. Y advised exercise and dietary modification to reduce Ms. X’s cholesterol level, but as these measures appeared ineffectual, he prescribed regular doses of atorvastatin (40 mg daily) and warned about possible muscle pains.
At follow-up 2 months later, Ms. X’s serum creatine-phosphokinase (CPK) was 872 IU/L (reference range, 30-135 IU/L). Subsequently, many different statins and other lipid-lowering drugs were prescribed in turn or concurrently, but with no improvement in LFTs or serum lipid levels. Over the ensuing months, Ms. X’s CPK level continued to increase (reaching 3,272 IU/L in May 2010), whereupon all drug treatment was withheld. Over the same period, she claimed to have experienced increasing muscle pains and calf tenderness (especially at night), and insisted that she repeatedly informed Dr. Y about these and various other symptoms, including bloating of her face, weight gain, yellowish skin, sleepiness, slowing down, and increasing tiredness. During some consultations, Ms. X was accompanied by her sister who therefore witnessed the doctor-patient interactions.
Over a 2-year period, the patient saw Dr. Y 11 times, but had no significant resolution of symptoms or blood test abnormalities. Nevertheless, her medical record contained no entry about any of the aforementioned symptoms or muscle examination findings. Ms. X claimed that finally, she presented Dr. Y with a printout of an internet search suggesting that her illness could be due to hypothyroidism. The tests performed thereafter yielded results consistent with severe thyroid deficiency (thyroid-stimulating hormone level >100 IU/L [reference range, 0.35-2.28 IU/L], free thyroxine level <0.40 ng/dL [reference range, 0.70-1.48 ng/dL]), and soon after, Ms. X was hospitalized and thyroid replacement therapy was commenced. The corresponding hospital medical record mentioned severe hypothyroidism and myositis, and in addition noted menorrhagia, cold intolerance, muscle pains, constipation, puffy face, and swollen fingers. All these are well-known classical features of hypothyroidism. Notably, her hospital ECG showed a slow heart rate (56 beats per minute) and very small amplitude P, QRS, and T waves in all leads, all of which are iconic ECG features of severe/moderate hypothyroidism.1,2
Over the ensuing 5 years, Ms. X raised complaints about her management by Dr. Y, though she had probably endured no permanent harm.
The Hong Kong Medical Council (HKMC) dismissed her claim, partly because her medical centre check-up in 2008 and hospital records in 2010 showed she had a low/normal body mass index (BMI) of 18.4 kg/m2 and 19 kg/m2, respectively; ≥30 kg/m2 is usually taken as overweight as might be expected in hypothyroidism. Ms. X nevertheless pursued a common law claim against Dr. Y, because during the prime of her life she unnecessarily had to endure 2 years of significant hardships and suffering. These so-called quantum issues fell into two categories. Firstly, she endured physical ill health, namely mental fatigue/slowing, cognitive decline, sleepiness, loss of confidence, memory loss, depression, worry/anxiety, cold intolerance, constipation, heavy periods, a swollen face, as well as muscle aches and weakness. Secondly, she had to contend with social burdens, namely work inefficiency leading to unemployment, social isolation and decline, as well as medical and legal expenses.
An expert report for the defence refuted the allegation of negligence, arguing that:
1) The HKMC did not accept the plaintiff’s complaint.
2) The medical record kept by Dr. Y was “not relevant”.
3) The disputed unrecorded symptoms amounted to accepting Dr. Y’s word vs the patient’s word.
4) Attributing high CPK levels and liver dysfunction to statins was reasonable, hypothyroidism being a very rare cause of such abnormalities.3-7
5) The patient’s low/low-normal BMI was not typical of hypothyroidism.
6) Overt hypothyroidism was probably a recent development and did not manifest as long ago as 2008.
These arguments were countered as follows:
1) The records kept by Dr. Y were meagre by any standard. Despite 11 visits, no complaints or physical examination findings were entered. Only test requests and results and the various drugs prescribed were noted. Maintaining clear, accurate, adequate and contemporary records has been a long-standing key principal stipulated in the HKMC’s Professional Code of Conduct.8
2) As to what the plaintiff told Dr. Y, on at least two occasions her sister witnessed the encounter and in a witness statement she testified as to what transpired.
3) Failure of several statins to reduce lipid levels should have prompted a rethink for possible secondary hyperlipidaemia.
4) Though unusual, Ms. X’s low/low-normal BMI was consistent with her having so-called forme fruste (a frustrated form) of hypothyroidism.
5) A request for past photos or even the patient’s ID card could have helped to discern changes in appearance.
6) Ms. X’s iconic ECG in 2008 was virtually identical to that obtained when she was hospitalized in 2010: bradycardia and very small amplitude QRS, T, and P waves were present in all leads. Nor did she exhibit any other conditions giving rise to small amplitude ECG wave excursions (eg, obesity, oedema, emphysema, or being moribund). For whatever reason, Dr. Y appeared to have ignored the ECG characteristics evident when Ms. X first presented, possibly because misleadingly the word “normal” was scribbled over the tracing.
7) As the very same iconic ECG features had been present for at least 2 years and had resolved completely after treatment, Ms. X’s hypothyroidism was almost certainly of long-standing and not a recent development. (Figure)
This case was finally settled out of court.