News: A patient with a history of urological issues filed a negligence claim against a hospital and physician after a procedure designed to treat his benign prostatic hyperplasia, an enlargement of the prostate gland causing urinary obstruction. The patient experienced several complications after the procedure.
During the trial, the patient moved for a directed verdict in his favor, requesting the judge rule in his favor without the need for the jury based solely on the opinion of his expert witness. In support, the patient argued there was “irrefutable” evidence indicating the physician breached the standard of care based on the totality of the evidence presented at trial. However, the judge concluded the jury should decide whether the defendant physician breached the standard of care and could consider the opinions of defendants’ experts as well. After a five-day trial, the jury found in favor of the physician and hospital on liability. Damages are yet to be litigated.
On appeal, the plaintiff argued the trial court erred in denying his motion for a directed verdict, but the appellate court affirmed the trial court’s ruling.
Background: In 2017, a 67-year-old man sought treatment for urological issues from a prominent physician. The patient’s medical profile revealed diabetes, high blood pressure, and nocturia (a condition that necessitates frequent urination at night), along with challenges such as pain during urination. The physician diagnosed the root cause as benign prostatic hyperplasia (BPH), a common condition in older men where the prostate gland enlarges, obstructing urine flow. The physician also found the patient’s bladder had herniated into his scrotum, demanding immediate repair.
Once the hernia was addressed in mid-2018, the physician recommended a transurethral resection of the prostate (TURP) to treat the BPH. The goal is to remove enough prostate tissue to relieve the obstruction without causing complications. The physician preferred a specific variation, referred to as the “button” TURP, and the procedure was scheduled for the end of 2018. Although this procedure is an established method to treat BPH, TURP does not use a standardized tissue removal metric. The amount of tissue that should be removed depends on the individual case. Removing too little tissue could leave the BPH symptoms unchanged, while excessive removal can cause permanent incontinence. The physician adopted a conservative approach for the plaintiff, removing a modest amount of prostatic tissue.
Postoperative complications arose, including urinary tract infections, blood clots, and kidney stones. But the patient’s main allegation was not the complications, but the procedure’s efficacy. Although initial follow-up visits suggested improvement, the patient resorted to self-catheterization and sought opinions from other urologists. Nine months after the first procedure, he underwent a second TURP that ameliorated his urological complaints.
The plaintiff’s complaint crystallized into two primary claims. The first claim alleged the physician did not remove enough tissue during the TURP procedure, breaching the standard of care. The second claim was that a reporting discrepancy emerged as post-surgery notes inaccurately detailed the procedure, suggesting that more tissue was removed than what was done.
During the trial, the plaintiff moved for a directed verdict against the physician and hospital on the basis that his expert’s testimony irrefutably established a breach in the standard of care. The defendant hospital opposed the motion, citing its own expert witnesses. The trial court rejected the plaintiff’s motion and sent the issue to the jury. The jury found in favor of the hospital, and the plaintiff appealed.
What this means for you: Medical negligence claims hinge on three primary components: defining the standard of care, the failure to meet this standard, and directly linking any negligence to the sustained injury. In this case, the chief point of contention was whether the physician breached the standard of care when he removed a limited amount of prostatic tissue. Experts on both sides were divided in their opinions for different reasons. While the plaintiff heavily focused on the procedure’s efficacy as the barometer of negligence, the court’s view was different. The efficacy of a procedure is only one factor when assessing whether the standard of care was met in accordance with the standards of the specialty. The lesson here is the standard of care is not solely rooted in whether a procedure is successful. Rather, the standard of care encompasses the broader framework of whether a reasonable physician, under the same conditions, would consider their actions to be reasonable. Medical procedures carry inherent risks, and positive outcomes are not guaranteed. However, the benchmark for the standard of care is not solely the result but also the process, judgment, and professional conduct throughout the patient’s treatment.
The case may have been avoided altogether if the patient’s informed consent was adequately recorded. A significant point of dispute was whether the plaintiff was adequately informed about the conservative approach the physician planned to take during the TURP. One of the defendants’ experts testified the physician exercised reasonable judgment in taking the conservative approach to minimize the risk of permanent incontinence. Effective and clear communication with patients is vital not only for trust, but also for legal protection. It is crucial to ensure patients are fully informed about procedures, risks, potential outcomes, and alternative treatments. Keeping detailed records of these discussions can serve as evidence if questions about the nature of informed consent arise later.
Another significant part of the case was the discrepancy in surgical notes. Postoperative notes inaccurately depicted the surgery, suggesting a more comprehensive removal than what transpired. After completing the TURP procedure, the physician indicated in the surgical notes that he took more material than he did. These notes were written by a surgical resident assisting the physician and were based on a recognized template describing the generic version of the button TURP procedure. It had not been modified to present an accurate picture of the procedure. The physician signed this record without realizing the mistake, but admitted the recounting of the procedure in the surgical notes was inaccurate. Although this error did not directly affect the plaintiff’s subsequent care, it introduced an element of doubt about the accuracy and reliability of the medical reporting. Accuracy in medical documentation is paramount. It is essential to review and ensure that all records, especially surgical notes, precisely reflect the procedures performed. Inaccuracies can lead to doubts about competence, integrity, and potentially give rise to legal issues.
These accuracy issues are becoming more problematic as our population ages and life expectancy lengthens. Assistants to independent practitioners have expanded far beyond medical students, interns, and residents. Physicians use physician assistants, nurse practitioners, nurse anesthetists, and midwives in increasing numbers. However, the requirement for a licensed physician to supervise all these care providers remains in place. Most physicians attest to providing this supervision by co-signing the notes made by these assistants in the patient’s medical record. It is an appropriate requirement if, in fact, the physician has observed the assistant at frequent intervals and read the note they are co-signing. Requiring electronic records compounds the likelihood of documentation errors in the medical record. These records encourage the copy/paste practice by all users. A patient with a red, swollen leg may find the ailment is present in the record on discharge but no longer present on the patient. Extreme caution must be taken to ensure the accuracy of what is signed.
REFERENCE
- Decided Sept. 21, 2023, in the Court of Appeals of Ohio, Eighth Appellate District, County of Cuyahoga, Case No. 112216.
Medical negligence claims hinge on three primary components: defining the standard of care, the failure to meet this standard, and directly linking any negligence to the sustained injury. In this case, the chief point of contention was whether the physician breached the standard of care when he removed a limited amount of prostatic tissue.
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