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    How patient obesity can impact malpractice litigation

    Lawsuit involving obese woman’s tricky stone surgery illustrates potential pitfalls

    Brianne Goodwin, JD, RNBrianne Goodwin, JD, RNHappy 2017. With the New Year being associated with resolutions of improved health and fitness and reducing the number on the scale, it seems a particularly appropriate time to share some information about how obesity impacts urologic care and treatment, and the impact of obesity on malpractice litigation.

    Also see: Top 5 malpractice articles of 2016

    Obesity increases the risk of malpractice litigation in all types of medicine, and obesity related claims have jumped by more than 60% in the last 10 years, according to a July 10, 2014 article in Clinical Endocrinology News. Currently, about 30% of the adult population in the United States is obese; by 2018 that number is expected to increase to 40% (Rev Urol 2015; 17:165-70).

    Obesity linked to urologic conditions

    With regard to urology, it is documented that obesity is associated with an increased risk for prostate cancer, renal cancer, nephrolithiasis, urinary tract infection, erectile dysfunction, hypogonadism, infertility, and incontinence (Rev Urol 2015; 17:165-70). Aside from physiologic implications, performing surgery on an obese patient is technically more difficult and poses a higher risk for postoperative complications (Rev Urol 2015; 17:165-70). The association between obesity and several urologic conditions may elucidate why malpractice claims might be more numerous with obese patients.

    It should come as no surprise to any clinician that patient obesity can require different management of care. This can range from use of a larger blood pressure cuff to stand-up diagnostic imaging or a different surgical incision or approach. Take the following lawsuit that went to a jury trial in Massachusetts:

    The plaintiff was an obese woman with a history of kidney stone disease. She alleged that the defendant urologist subjected her to unnecessary surgery that was improper based upon insufficient diagnostic studies. The plaintiff contended that she experienced post-surgical complications and continued to suffer as a result of the alleged unnecessary surgery.

    The evidence indicated that the defendant urologist, prior to electing to proceed with surgery, attempted lithotripsy to break up the kidney stones. According to the defendant, because of the plaintiff’s obese condition, she was unable to withstand the procedure. Believing that the kidney stones had been sufficiently identified on x-ray, the defendant urologist recommended surgery. That recommendation was based solely upon the x-rays and the plaintiff’s medical history. The plaintiff was not exhibiting clinical symptoms of kidney stones, but would not have been expected to have such complaints due to the presence of a ureteral stent.

    During the surgery, the defendant was unable to locate any kidney stones. The plaintiff’s expert urologist testified that the defendant deviated from the standard of care in proceeding with surgery without performing more specific diagnostic studies, including a retrograde pyelogram, to confirm the presence of kidney stones. The plaintiff’s expert maintained that what the defendant assumed was a kidney stone on x-ray was actually a calcified lymph node.

    The defendant countered that he acted appropriately in electing not to perform a retrograde pyelogram because he had attempted such a procedure upon the plaintiff 1 month earlier and without success, due to the plaintiff’s obese condition. The defendant’s expert urologist testified that the defendant acted properly in electing to perform surgery upon this plaintiff based on her history and what appeared to be a kidney stone on x-ray. The defense expert opined that in view of the fact that the plaintiff was not a candidate for lithotripsy, the defendant acted reasonably under the circumstances in recommending surgery. The jury found for the defendant urologist.

    A review of claims demonstrates that patients who have experienced an adverse medical event leading to a medical malpractice claim are frequently noted to be obese, according to The Doctors Company, a physician-owned medical malpractice insurer (bit.ly/Obesitycrisis). The reason for a frequent number of claims by obese patients is not entirely clear, but lends itself to brainstorming some practice pointers to help in avoiding litigation.

    Next: Obesity-related documentation critical

    Brianne Goodwin, JD, RN
    Ms. Goodwin is manager of clinical risk and patient safety at Cambridge Health Alliance, Cambridge, MA.

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