Jury says doctor didn't do enough to help obese smoker

In the Courts. By Tanya Albert, AMNews staff. May 12, 2003.

As scientists better understand how excess weight, age, sex, smoking and stress increase the risk for heart disease, one Cleveland jury says physicians have a greater responsibility to make sure patients keep those factors in check and to refer patients with risk factors to specialists more quickly.

They backed up that opinion with a $3.5 million judgment against a Cleveland internist whose patient died of a heart attack. An autopsy performed on the 54-year-old, overweight man showed coronary artery disease.

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Some experts argued that the doctor, Franklin Price, MD, did everything possible to try to help the patient, Lawrence Smith. They say people need to take more personal responsibility for what they do to their bodies.

Other experts, though, say the case is about whether Dr. Price did enough to help Smith avoid a heart attack given his risk factors.

In addition to being overweight and older than 50, Smith also smoked and had a stressful job.

Six jurors said Dr. Price could have done more, while two said he did enough. (Civil juries in Ohio do not have to be unanimous for the plaintiff to win.)

The case is sure to trouble physicians, who will be wondering what perfect combination of their care and patient responsibility is going to put them on the winning end of a lawsuit.

"If an internist is going to take it upon himself or herself to be the first level of diagnosing heart disease or to be the gatekeeper before a patient sees a cardiologist, they have to be aware of what impact risk factors have on their responsibility," said Peter H. Weinberger, who represented Smith's wife, the plaintiff. "They have to know when they have the obligation and the duty to have someone else look at a patient."

The obligation, Weinberger says, kicks in when a patient has several risk factors and an abnormality on an electrocardiogram.

Michael J. Hudak, who represented Dr. Price, said a physician can meet the standard of care by telling a patient to see a specialist, discussing the hazards of obesity and smoking and offering to write prescriptions for medications that can help. But, at some point, accountability rests with the patient.

"There is a certain amount of personal responsibility involved," Hudak said. "A patient needs to want to change habits."

Consequently, Hudak said, the most important lesson for physicians is something that they've heard thousands of times, but that can't be stressed enough: Document, document, document.

"If you have a patient who is not achieving goals, documentation is key," said Hudak, who said he is optimistic Dr. Price will be able to win the case on appeal. "You can establish what you tried to do and record personal thoughts on why a patient is not achieving the goals, such as 'the patient indicated they enjoy smoking and don't want to quit.' "

The physician-patient relationship of Dr. Price and Smith unfolded in court records.

Smith first saw Dr. Price in 1994, five years before his death in June 1999. Dr. Price saw Smith a few times during that first year. He monitored Smith's blood glucose because he believed the man was a latent diabetic. He also ordered other lab tests. In August 1995, Dr. Price saw an elevated PSA level; a prostate biopsy indicated cancer. In October 1995, Smith underwent a radical prostatectomy.

Smith saw Dr. Price, who is also a hematologist-oncologist, on a regular basis for follow-up for his cancer, as well as general health concerns. According to court documents, Dr. Price frequently expressed concerns about Smith's weight and blood sugar. Dr. Price made dietary recommendations and encouraged Smith to stop smoking. The physician offered nicotine patches and nicotine gum to help Smith stop smoking. To help him lose weight, Dr. Price gave Smith pamphlets about weight loss and discussed the weight-loss drug Redux, Hudak said. Dr. Price prescribed an oral hypoglycemic agent to help control blood glucose, according to court records.

The last time Dr. Price saw Smith, two months before his death, the physician also re-initiated medication to treat Smith's diabetes, according to court documents.

Hudak said Dr. Price did his job. When Dr. Price discussed putting Smith on medication for weight loss or smoking, Smith told the physician he wanted to continue to try to do it on his own, Hudak said.

It's one thing for a physician to offer help, Hudak said, "but another for the patient to have the willpower" to lose weight or stop smoking or the desire to use medications to aid in achieving those goals.

Weinberger agrees it's important for physicians to document discussions with patients about lifestyle changes.

"Modification of lifestyle should be tried initially before someone is put on drugs, but after three to six months of attempting, the doctor needs to have the discussion of using drugs and document it," Weinberger said. "If a patient says he wants to keep trying lifestyle modification, it needs to be documented."

Beyond helping patients change habits is the question of referral to a cardiologist.

Dr. Price contends that two months before Smith died, he recommended seeing a cardiologist for an evaluation and stress test and gave Smith a cardiologist's name, address and phone number. Dr. Price made the recommendation based on Smith's complaints about right arm pain that occurred when he was stressed and a question of whether there were some possible changes in his ECG, according to court records. Dr. Price and experts on his behalf testified at trial that the ECG wasn't ominous and did not raise red flags. Also, they said, ECGs that Dr. Price recorded over the years didn't show a deteriorating condition.

"The physician followed the standard of care," Hudak said.

Smith's wife contends, in court documents, that Dr. Price misread her husband's ECGs for years and never referred him to a cardiologist. And she said that even if the referral had been made, it should have been made immediately "rather than as [Dr. Price] has testified ... to see a cardiologist in 30 days." Also, experts who testified for her said that Smith should have been referred to a cardiologist years before based on the ECG and his risk factors.

"The jury felt the doctor dropped the ball," Weinberger said.

A growing trend?

Lawsuits similar to the one against Dr. Price aren't a trend, per se. But he isn't the only physician facing a lawsuit along these lines. At least two similar cases are pending in Ohio and more have cropped up in other states.

Stephen Glasser, MD, who specializes in cardiovascular diseases, said he doesn't believe the case against Dr. Price is fundamentally different from other cases that question the standard of care that a patient receives.

And he predicts there will be more cases in the future.

"We have more information that reducing risk factors makes a difference," said Dr. Glasser, from Minnesota, who served as an expert witness for Smith's wife in the trial. "Also, now there is more we can do to mitigate the risk factors. For example, in the past, there wasn't anything to help a patient stop smoking."

Albert is a staff writer covering legal issues.

Copyright 2003 American Medical Association. All rights reserved.