Multiple urinalyses revealed hematuria in a 49-year-old woman, but her urologist failed to run any blood tests
As a urologist with nearly 30 years' experience, Dr. T, 58, was accustomed to having patients referred to him by other doctors. But he never expected to be sued for not making a referral himself.
The patient, Ms. Y, 49, had been referred by her general practitioner, Dr. A. According to the re-ferral note, a urinalysis taken as part of a routine checkup had found blood and protein in Ms. Y's urine. A follow-up test two months later showed the same abnormal results, prompting the referral.
A urinalysis performed during her first visit to Dr. T revealed hematuria. Over the next two months, the urologist saw Ms. Y three more times. Urinalysis at each visit detected hematuria.
Despite these findings, Dr. T did not run any blood tests. He assumed that Dr. A had run them already and would have notified him of abnormalities. The urologist believed watchful waiting was appropriate under the circumstances and did not order any kidney function tests.
Frequent urinalyses ordered Ms. Y diligently returned for follow-up every two to three weeks, but after the fourth visit she was fed up with what she perceived as Dr. T's failure to do anything but check her urine. Three days after that visit, she returned to Dr. A, complaining of nausea and weight loss. He ordered blood and kidney function tests, which revealed anemia, high blood urea nitrogen (BUN), and abnormal creatinine levels.
As soon as he got the test results, Dr. A checked Ms. Y into the hospital, but she went into renal failure and was put on dialysis. Di-agnosed with glomerulonephritis, she underwent kidney transplantation within a year.
Ms. Y and her husband then consulted a plaintiff's attorney, who hired an expert nephrologist to review her records. When the expert confirmed that Ms. Y indeed had a case, the couple sued Dr. A and Dr. T.
At trial, Ms. Y described the continued pain and ill health associated with her disease and transplant. Her husband testified that her condition had harmed their relationship such that they no longer were able to engage in marital relations.
Then the expert nephrologist took the stand to describe the applicable standard of care. He stated that about 50% of women with essential hematuria have glomerulonephritis.
“Based on your training and experience, did Dr. T's failure to refer Ms. Y to a nephrologist constitute a deviation from the standard of care?” the plaintiff's attorney asked.
“Yes. Ms. Y's health suffered greatly as a result,” the expert said.
“If Ms. Y had been referred to a nephrologist, what would have been the likely outcome?”
“A nephrologist would have started immunosuppressive therapy early on in her disease, and he would have had a very strong chance of turning the whole process around, without its resulting in complete kidney failure,” the expert stated.
On cross-examination, the defense lawyer asked the nephrologist to explain how he concluded that 50% of women with hematuria have glomerulonephritis. The expert patted the large binder he had brought with him to the witness stand, citing the results inside.
The defense lawyer objected vigorously, arguing that he had not seen the binder's contents. In any event, he argued, the expert should testify from his own experience and training. The judge agreed and instructed the expert to put aside the binder. At that point the doctor modified his response.
“In my 35 years as a nephrologist, about half of my female patients with hematuria have glomerulonephritis,” he said.
Dr. A and Dr. T each testified in his own defense. Dr. A said he had referred Ms. Y to Dr. T because of the hematuria and that he assumed Dr. T would handle the case from there. Dr. T stated that he was monitoring the patient's condition but assumed Dr. A had run blood tests and would have notified him of any abnormalities.
After a few hours' deliberation, the jury exonerated Dr. A and found Dr. T negligent, awarding Ms. Y $500,000 in damages.
Legal theory
Expert witnesses play an important role in any malpractice proceeding. Many cases are won or lost on the basis of expert testimony. In this case, the expert stated that referral to a nephrologist would have resulted in earlier treatment and an improved prognosis for Ms. Y. This assertion was the linchpin of the plaintiff's claim that Dr. T had been negligent.
The defense lawyer tried to discredit the expert by objecting to the binder he carried. It was unfair, said the attorney, because the expert did not say anything about the studies during the pretrial discovery process, thereby blindsiding the defense. Even worse, the lawyer continued, the fact that the expert brought the binder to the stand showed that he needed a crutch. After the judge's ruling, however, the expert's own knowledge and experience allowed him to testify effectively—even without his impressive prop.
Protecting yourself
Dr. T could have avoided this lawsuit had he done one of two things: run lab tests to check for abnormal kidney function, or referred Ms. Y to a nephrologist once it was clear that the hematuria was not resolving. The old adage about the danger of assuming is also obviously in play. Had Dr. T made a simple phone call to check whether Dr. A had had the blood tests run, he could have saved himself—and his patient—a great deal of pain.
Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.