Case narrative

As chair of the ethics committee, I (RAP) received a phone call from a second-year cardiology research fellow requesting advice about a vexing case. She asked the following question:

I asked the fellow to tell me more about the case. She reported that a 68-year-old patient with a host of chronic medical problems including emphysema, diabetes, and congestive heart failure went to an urgent-care clinic for evaluation of increased difficulty in breathing. A moonlighting resident examined the patient and ordered an EKG, chest X-ray, and lab tests. The resident interpreted the EKG as clinically insignificant and thought that the chest X-ray showed findings consistent with the patient's emphysema. The resident also noted what appeared to be a possible infection behind the heart. Laboratory tests showed a mildly elevated white blood cell count, but no tests were ordered to rule out a heart attack. The resident diagnosed a possible pneumonia, prescribed antibiotics, and told the patient to return if his symptoms did not improve.

The resident, a trainee at a local medical center, worked in freestanding urgent care clinics during off-hours with a business partner who was an internal medicine fellow.