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Past Internal Medicine Case Conferences

Feel free to use the following case conferences for educational purposes. We only ask that you credit this source when using our materials.

  • 2003
  • January 2003: Physicians And The Pharmaceutical Industry: The Difference Between Being Taught And Being Sold (Case and questions)
  • February 2003: Medical Mistakes: How We Deal With Them (Case and questions)
  • March 2003: Training on the Nearly Dead and Newly Dead (Case and questions)
  • April 2003: Ethnic and Racial Discrimination in Medical Treatment (Case and questions)
  • May 2003: The Weitzel Trials: Implications for Internists (Case and questions)
  • June 2003: Malpractice: Patterns and Prevention for Internists (Case and questions)

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January 2003 Internal Medicine Housestaff Conference

Physicians And The Pharmaceutical Industry: The Difference Between Being Taught And Being Sold

Case: Alice is an Internal Medicine Resident, married with one child. Her husband is a cardiology fellow. They finished medical school with loan repayment obligations of about $50,000. She intends to do a fellowship in infectious disease when she finishes her residency and then pursue an academic career. She has her regular outpatient clinic assignment at LDS Hospital. She reads the New England Journal of Medicine and Annals of Internal Medicine regularly, and attends most Departmental Grand Rounds and noon lectures.

She recently received an invitation from a pharmaceutical company to attend a dinner with her spouse at LaCaille and hear a presentation about a promising new agent for the treatment of AIDS and HIV infection. The speaker is a nationally acknowledged expert who conducted some of the most important clinical trials with this agent. The invitation states that if the resident attends the dinner the company will be giving her a check for $100 to defray her expenses and compensate her for her time.

Alice checks her call schedule and discovers that she is free on the night of the dinner. The invitation asks for a response and gives a phone number. Before calling, Alice decides to consult with her colleagues about the dinner. She has several questions: Did they get an invitation? Several, but not all did. Are they going? Some are. What do they think about whether she should go and why?

Questions

1) Pharmaceutical companies spend $8,000 to $13,000 a year on each physician. T F
2) The average physician meets with a pharmaceutical representative four times a month. T F
3) Faculty meet with pharmaceutical representatives more often than residents do. T F
4) Interactions with pharmaceutical representatives are associated with formulary addition requests. T F
5) Most (61%) of Internal Medicine Residents in a recent study believed that industry promotions and contacts did not influence their prescribing. T F
6) The residents in that study felt that 84% of other physicians were influenced. T F
7) 35% of Internal Medicine Programs have guidelines related to physicians and the pharmaceutical industry. T F
8) The University of Utah has such a guideline. T F
9) Accepting an invitation and money in the conference example would violate AMA and American College of Physicians Guidelines. T F
10) Cost seemed to be the most important factor when residents decided whether an industry gift was inappropriate. T F

Answers: 1-F, 2-T, 3-T, 4-T, 5-F, 6-F, 7-T, 8-T, 9-F, 10-F

February 2003 Internal Medicine Housestaff Conference

Medical Mistakes: How We Deal With Them

Case: Mrs. "M" is a 42-year old woman with Type I diabetes. Her father, a diabetic, died at age 60 of a myocardial infarction. Her mother and older sister have breast cancer. She was hospitalized in August of 2002, with diabetic ketoacidosis that was managed successfully. She was readmitted in January 2003, because of a seizure. Investigation established that she had metastatic breast cancer with a 4 cm. primary tumor in her right breast.

The resident who reviewed the chart from August did not find a breast exam recorded. He realized that Dr. First, the resident who cared for Mrs. "M" in August, was currently on one of the other medicine teams in the hospital. On the way to morning report, he walked with her and told her about Mrs. "M". Dr. First was upset and wondered what to do and what to say and to whom.

1) Internal Medicine residents report that the most common type of mistake is faulty communication. T F
2) Internal Medicine residents report that the most common type of mistake is an error in diagnosis. T F
3) Slightly more that half of Internal Medicine residents surveyed reported discussing their most significant mistake with their attending. T F
4) Slightly more that half of the residents told patients or families about that mistake. T F
5) The error rate in controlled studies ranges from 10-63%. T F
6) Computerized reminders have been shown to reduce medical errors. T F
7) Having a pharmacist participate in rounds reduces medical errors. T F
8) In a scenario of a moderate or major mistake, patients were more likely to sue if informed. T F
9) Virtually all patients want their physician to acknowledge even minor mistakes. T F
10) Attributing a mistake to job overload predicts a constructive response. T F

Answers: 1-F, 2-T, 3-T, 4-F, 5-T, 6-T, 7-T, 8-F, 9-T, 10-F

March 2003 Internal Medicine Housestaff Conference

Training on the Nearly Dead and Newly Dead

Case:Mr. L, a 66 year old man, was admitted because of jaundice, weakness, and confusion. Since the death of his wife 4 years ago, he had been quite reclusive. His sister, who visited about once per month, was alarmed by the rapid change in his condition and brought him to the hospital. Physical and laboratory exam confirmed liver failure and encephalopathy. His liver function rapidly worsened, he developed renal failure and was transferred to the ICU. Diagnostic studies did not reveal the cause of his liver disease and a liver biopsy was contraindicated because of a coagulopathy. On the fourth hospital day, he developed fever, lactic acidosis and hypotension. Shortly thereafter, he had a cardiac arrest. He did not respond to five minutes of chest compression, Ambu breathing and intravenous agents. The attending, observing the resuscitation, was about to ask the resident to stop, but first asked if any of them needed experience with intubation. A first year resident said that he hadn't intubated a patient before and the attending invited him to go ahead. After a successful intubation, but no cardiac response, the attending pronounced the patient dead. The ICU Fellow, unsure whether an autopsy would be done, proposed that the R1, who needed to learn how to do a liver biopsy do one, and possibly help discover the cause of Mr. L's liver failure.

1) When asked to consent to the intubation of a newly dead family member, for the purposes of training, a majority of families gave consent. T F
2) When asked to consent to a postmortem cricothyrotomy on a newly dead family member, a majority of families gave consent. T F
3) A majority of people report they would give consent to the teaching of lifesaving skills on a newly dead family member, if asked. T F
4) Most people believe consent should be sought before performing T F training procedures on the newly dead. T F
5) The type of training procedures to be performed makes no difference T F in people's willingness to give consent. T F
6) Several studies found a correlation between willingness to consent to T F postmortem training procedures and willingness to be an organ donor T F

Answers: 1-T, 2-F, 3-T, 4-T, 5-F, 6-T

April 2003 Internal Medicine Housestaff Conference

Ethnic and Racial Discrimination in Medical Treatment

Case:Coretta Brown, a 63-year-old African-American woman was seen in the Outpatient Clinic by an Internal Medicine resident (male, Caucasian, age 28). She was in the clinic for follow-up on her diabetes, hypertension, and renal insufficiency. All were under fair control. The resident, as he routinely did, asked if she had an Advance Directive, she did not. He explained what it was and asked if she wanted to complete one. She declined.

Over the ensuing two years, she had a series of small strokes and became mentally incapacitated. Her renal failure worsened. Her daughter agreed when dialysis was proposed and she asked about the possibility of renal transplant. The nephrologist (female, Caucasian, age 40) listed Mrs. Brown as a potential recipient, but no compatible kidney became available. Her mental status continued to deteriorate. Her daughter continued to care for her mother and bring her regularly to her dialysis sessions.

1) The recipient of the first fully implantable heart was an African American. T F
2) A large majority of Americans believe that Blacks receive the same quality of healthcare as whites. T F
3) Racial and ethnic minorities experience lower quality healthcare than non-minorities even when insurance status and income are controlled. T F
4) African Americans are less likely to receive cardiac medication, CABG surgery, and they experience higher cardiac mortality. T F
5) African Americans undergo amputation at a rate 6 times higher than their white medical peers. T F
6) HIV/AIDS treatment disparities between whites and blacks can be explained by education, by CD4 cell count and insurance coverage. T F
7) Disparity in treatment of cardiac disease between whites and blacks is largely attributable to more common treatment refusals from black patients. T F
8) When presented with black and white actors reporting the same pain symptoms male physicians prescribed twice as much analgesia for the white "patients." T F
9) Audit studies of mortgage lending, housing, and employment practices using paired "testers" demonstrate persistent discrimination against African Americans and Hispanics. T F

Answers: 1-T, 2-T, 3-T, 4-T, 5-F, 6-F, 7-F, 8-T, 9-T

May 2003 Internal Medicine Housestaff Conference

The Weitzel Trials: Implications for Internists

Case: The three children of Mary Crane - Glen Crane, Cathy Charlesworth and Karen Bringhurst - filed a wrongful death lawsuit against Weitzel in July 2000, alleging his conduct was negligent and below the standard of care he was expected to provide.

Weitzel was charged with five cases of first-degree felony homicide. He was convicted July 10, 2000 of the lesser included charges of manslaughter in Crane's death and the death of 93-year-old Judith Larsen, and of negligent homicide in the deaths of Ellen Anderson, 91; Lydia Smith, 90; and Ennis Alldredge, 83. At the time of their deaths, Weitzel was serving as the head of the Davis Hospital and Medical Center's geriatric-psychiatric unit, to which the patients had been transferred after they reportedly exhibited disruptive behavior at other long-term-care facilities. All died within a 16-day period in December 1995 and January 1996.

The Crane lawsuit was the second civil suit filed against Weitzel. The other, filed June 1, 2000 in 3rd District Court, sought recompense for family members of Alldredge.

As with the Alldredge lawsuit, the Crane family asserted the Davis Hospital and Medical Center and various members of its medical staff, Weitzel and the Texas-based company that hired him were responsible for Crane's death.

The lawsuit alleges neither the hospital nor the geriatric-psychiatric unit's parent company "bothered to set up adequate safeguards or oversight committees to protect patients of their geropsychiatric program, remaining knowingly and recklessly indifferent to the safety of their patients."

Both organizations were "negligent, careless and indifferent" in hiring Weitzel, who was under investigation in Texas and is no longer allowed to practice medicine in California, the suit states.

In January of 2001, the judge ordered a new criminal trial on the ground that prosecutors had failed to tell defense attorneys about an expert witness with views favorable to the defense. Weitzel was acquitted of the same charges at the second trial in November 2002.

1) The standard of proof in tort law is "preponderance of evidence." T F
2) The standard of proof in criminal law is "beyond a reasonable doubt. T F
3) An unintentional bad outcome in the course of medical care cannot be the subject of criminal prosecution. T F
4) In criminal law, "a person acts recklessly, or maliciously, with respect to circumstances surrounding his conduct or the result of his conduct when he is aware of but consciously disregards a substantial and unjustifiable risk that the circumstances exist or the result will occur." T F
5) Robert Weitzel, a psychiatrist, was found guilty of manslaughter in a case involving the death of five patients. T F
6) Robert Weitzel was acquitted of manslaughter charges in a case involving the deaths of five patients. T F
7) Physicians are likely subject to criminal prosecution if their patients die shortly after receiving appropriate amounts of opiates for medical indications. T F

Answers: 1-T, 2-T, 3-F, 4-T, 5-T, 6-T, 7-F

June 2003 Internal Medicine Housestaff Conference

Malpractice: Patterns and Prevention for Internists

NOTE: For June Housestaff Conferences we will be using the same case we used for the February 2003 Conferences, but we will focus on the malpractice issues instead of the medical mistakes perspective.

Case: Mrs. "M" is a 42-year old woman with Type I diabetes. Her father, a diabetic, died at age 60 of a myocardial infarction. Her mother and older sister have breast cancer. She was hospitalized in August of 2002, with diabetic ketoacidosis that was managed successfully. She was readmitted in January 2003, because of a seizure. Investigation established that she had metastatic breast cancer with a 4 cm. primary tumor in her right breast. The resident who reviewed the chart from August did not find a breast exam recorded. He realized that Dr. First, the resident who cared for Mrs. "M" in August, was currently on one of the other medicine teams in the hospital. On the way to morning report, he walked with her and told her about Mrs. "M". Dr. First was upset and wondered what to do and what to say and to whom.

Malpractice: Basic Information

Malpractice is a tort. This means that a suit for malpractice aims to shift losses, from the alleged victim of the harm to the alleged cause of the harm (or, quite typically, the insurer of the alleged). There are both efficiency and fairness reasons why one might support or object to this shift. On efficiency grounds, one might ask what are the overall costs of allowing recoveries in this kind of case, such as reducing the willingness of providers to offer the care in question (when family practice physicians in rural areas stop doing obstetrics, for example). One might also ask who's the best cost avoider (usually the physician, because he/she has more knowledge) and what the optimal level of cost avoidance is. On fairness grounds, one would consider who's at fault; it seems unfair for someone who did not cause an injury, or who gave care that met the standard of care, to bear the costs of the loss.

A common misunderstanding of malpractice among physicians is that it's like a "crime." Consider language such as "found guilty of malpractice" or "convicted of malpractice." Strictly speaking, this language is a confusion; all a malpractice recovery does is shift the loss from the person bringing the suit to the defendant.

There are four elements in a malpractice suit:

  1. Duty of care (a provider/patient relationship)
  2. Breach of that duty (failure to meet the standard of care)
  3. Causation
  4. Harm

If a plaintiff fails to prove any one of these elements, the case should fail. A frequent failure is proof of cause; there may be substandard care, accompanied by harm, but without proof of causation. A growing area of malpractice litigation of special interest to primary care physicians is the failure to diagnose: for example, a breach of the standard of care that results in the failure to diagnose cancer at an early, possibly more treatable, stage.

Current proposals for tort reform focus on the impressive mismatch between the frequency of medical injuries caused by failures to meet the standard of care, and actual malpractice recoveries. One concern is that, given the mismatch, deterrence signals are woefully inadequate. Another concern is fairness: many people injured by substandard health care never make it into the tort system at all, and some that do make it into the tort system may have experienced bad outcomes but not malpractice. A major issue for public policy in this area is whether it is worse to have a system that compensates some who should not receive it, or to have a system that fails to compensate some who should receive it.

- Leslie Francis, Ph.D., J.D.

1) Successful malpractice action must show only that there was a breach of the standard of care and that the patient experiences an adverse outcome. T F
2) A recent Utah statute permits doctors to require that their patients waive the right to a trial for malpractice claims and accept binding arbitration, except in the context of any health care provided in a hospital emergency department. T F
3) Utah has a cap on damages for pain, suffering and inconvenience of $400,000, with inflation indexing for years after 2002. T F
4) A patient cannot request an award of a specific dollar amount in a medical malpractice complaint. T F
5) Internists are most often sued for failure to diagnose life-threatening conditions. T F
6) Medical residents can be named in medical malpractice claims and must provide their own attorneys. T F
7) The law requires that a physician with special expertise must serve as an expert witness. T F
8) With two exceptions, one for a foreign object and one for concealment, a malpractice action must begin within two years of the time the patient discovers, or reasonably should have discovered, the injury, but in any case not more than four years from the date of the alleged act of malpractice. T F
9) In Utah, all medical malpractice claims must be reviewed by a prelitigation panel unless the parties agree to waive the hearing. T F
10) The prelitigation panel's decision may be used as evidence in a subsequent lawsuit. T F

Answers: 1-F, 2-T, 3-T, 4-T, 5-T, 6-F, 7-F, 8-T, 9-T, 10-F

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