“Dr. Vance,” she said, “your physical exam note describes mild tenderness on palpation. Three nurses documented severe distress and difficulty lying flat due to pain. How do you explain the discrepancy?”
Vance shifted. “Patients often exaggerate. Part of clinical judgment is distinguishing subjective complaints from objective findings.”
“So your position is that the nurses were mistaken?”
“My position is that I relied on my own exam.”
“An exam nursing documentation suggests lasted approximately ninety seconds. Is that accurate?”
“I performed an adequate examination.”
“Did you assess rebound tenderness?”
“I don’t recall specifically.”
“Did you assess for guarding?”
“I don’t recall.”
“Rigidity?”
“I don’t recall the exact components of the exam.”
“Did you document them?”
“No.”
“Why not?”
“I documented what I considered clinically relevant.”
She let the silence hang for a moment. “You documented that the patient appeared to be exhibiting drug-seeking behavior. What specific behaviors led you to that conclusion?”
“He requested pain medication.”
“According to the nursing notes, he requested relief for severe pain after approximately three hours in the emergency department. He did not request narcotics specifically. Is asking for pain relief after hours of acute abdominal pain, in itself, evidence of drug-seeking behavior?”
“In my experience, genuine medical emergencies present differently.”
“Differently how?”
He hesitated, and everyone in the room felt it. “The patient’s demeanor. His appearance. His communication style. It suggested someone focused on obtaining drugs rather than treatment.”
“Could you be more specific about his appearance?”
Another pause. Too long. Fatal. “He had tattoos,” Vance said finally. “Piercings. An unconventional appearance.”
“And in your medical training,” the attorney asked, her voice calm enough to be lethal, “were you taught that tattoos and piercings are contraindications for serious medical illness?”
The room went perfectly still.
“No,” Vance said.
“Were you taught that tattoos and piercings are predictive of malingering?”
“No.”
“Were you taught that they diminish the likelihood of appendicitis?”
“No.”
“Then why did they matter?”
He flushed. “Emergency physicians develop instincts.”
“Instincts based on appearance rather than clinical presentation?”
“That’s not what I said.”