Juries often find for the physician
The use of methotrexate in an early intrauterine pregnancy is a current and ongoing concern. In this case, despite the weight of the evidence, the jury rendered a defense verdict, highlighting the fact that juries often find for physicians in malpractice cases. This was a fortunate outcome. However, the defense had to address several issues that made the case more difficult to defend.
Issues regarding hCG levels
In a stable patient, the physician is advised not to treat a suspected ectopic pregnancy with methotrexate based on a single hCG level, unless the ultrasound is definitive in the diagnosis. This patient had serial hCG levels that were rising appropriately. Although an appropriate increase in hCG level does not preclude the diagnosis of an ectopic pregnancy, it should cause the physician to reevaluate the diagnosis and treatment plan. For several reasons, the physician should know the hCG level results before administering methotrexate. An appropriate increase, as in this case, should prompt a reassessment of the patient. In addition, the hCG may be at such a level that, even in the case of a definite ectopic pregnancy, methotrexate may have a higher failure rate. Thus, surgical treatment may be more appropriate for the patient.
Issues regarding the ultrasound studies
Physicians should review prior imaging studies and compare the findings with current studies. Electronic health records, which often allow remote access to staff physicians, have facilitated this. A review of prior ultrasound findings, including the images if available, is helpful in constructing a timeline and arriving at the appropriate diagnosis.
Ultrasounds were performed in the physician’s office with several different machines. The images were of relatively poor quality, likely related to the age of the ultrasound machines. Contemporary ultrasound machines should be used to acquire appropriate images. In addition, machines should undergo preventive maintenance on an annual basis to assure ongoing quality imaging.
Images from the various studies were saved on thermal print paper, as is done frequently in offices. However, retaining images in a digital format is preferable, to maintain the quality of the originals. This can be done by using a picture archiving and communication system (PACS), in a local server, in the hospital’s PACS system, or in one of the various cloud-based PACS systems. Alternatively, one can migrate the images stored on an ultrasound machine’s hard drive to a DVD on a monthly basis and save the DVD in a secure location for the statute of limitations of one’s state.
Office documentation was sparse and did not meet the then current guidelines for evaluation and management documentation. The history and physical findings should be adequately documented and correlated with laboratory and imaging findings. The assessment and plan should reflect one’s diagnostic assessment and treatment options. Finally, a discussion of the risks of the planned treatment and alternatives should be documented.