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JUNE 2018

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Medical Malpractice Review

John J. Rush, M.D., FACEP, MBA, MHA 

The Longevity Physicians Insurance Company introduces the next malpractice case review and analysis in our series. We hope to remind Age Management Medicine physicians of some of the perils illustrated by recent malpractice verdicts or awards. Today, we present a malpractice case that is pertinent to the practice of Age Management Medicine.

The Case 

A patient in her early 40s complained to her primary care physician of a 10-year history of eye irritation. She told him that because nonprescription eye drops were no longer effective, she wanted a prescription. The physician assessed the patient as having allergic conjunctivitis and referred her to an ophthalmologist.

She complained about her eyes being red and painful again 5 months later, at which time her PCP again referred her to an ophthalmologist. During the patient's visit 2 years later for a cough and sore throat, the PCP documented the patient's chronic red eyes and noted that antibiotics had not helped her. The PCP then referred her to a different ophthalmologist.

In a visit a year later, the patient complained that the area around her right eye had been red for more than a month.  The PCP prescribed Tobradex® (tobramycin/dexamethasone), a steroidal anti-inflammatory and antibiotic, and advised her to follow up with an ophthalmologist if she did not improve. When the patient called the next month asking for a refill, the PCP called back to ask if she had followed up with an ophthalmologist. She responded that she had seen several ophthalmologists, who diagnosed chronic eye irritation and allergies, and who gave her drops to use daily. But she told her PCP that she also had flare-ups of "pink eye" and that the Tobradex worked the best for that.

The PCP approved the refill but charted that he advised the patient that Tobradex was not for continuous use because it could cause glaucoma and cataracts. He again instructed the patient to follow up with her ophthalmologist.

The PCP approved telephone requests for refills twice again several months later, and when the patient called early the next year for another refill, the PCP approved it and advised her to follow up with her ophthalmologist. A few months later, the patient called, complaining that the Tobradex was not helping the continued redness around her eyes.

She was told to come in to the clinic for evaluation or to see her ophthalmologist.

Early the next year, the patient returned to the PCP with a variety of complaints, including a request for a referral to another ophthalmologist for possible cataracts.

The ophthalmologist indeed diagnosed cataracts and later reported to the PCP that the patient had been using the Tobradex four times a day for 2 years. When the PCP spoke with the patient over the telephone about the diagnosis, he explained that the Tobradex had probably caused the cataracts. When he noted to the patient that the label on the medication advised against using the medication for more than 5 days, the patient responded that she was never told to follow directions or read the labels.

The patient sued her PCP and her pharmacy for the damage to her eyes from the Tobradex. The dispute was resolved without going to trial.


Physicians can avoid inadvertent overprescribing by developing specific routines—such as reviewing a patient's medication flow sheet—when issuing refills.

Such routines can be more effective than simply assuming that the patient remembered the doctor's verbal advice or followed the warning on the label, important as those latter two certainly are.

Yes - prescription medications often contain detailed information sheets or warning labels. 

No - these warnings will not relieve the prescribing physician of his or her responsibility to monitor the patient's actual use of the medication in the refill process.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.




Longevity Physicians Insurance Company was created because traditional medical malpractice insurance companies simply don’t understand Age Management Medicine. Typical medical malpractice rates offered to AMM physicians are based upon family practice/internal medicine rates. Age Management Medicine physicians see less patients, do less procedures, and rarely attend patients in a hospital setting. So why do AMM physicians pay malpractice insurance companies for risks that don’t exist?

According to a recent survey, AMM physicians are paying average malpractice insurance rates of between $10,000 and $14,000/year, depending upon the State in which they practice. In addition, LPIC has found that many carriers do not specifically cover hormone replacement therapy in the policy. LPIC premiums are about half of typical malpractice rates.

John J. Rush, M.D., is Chairman & CEO, 
Longevity Physicians Insurance Company. Dr. Rush attained his medical degree from Northeastern Ohio Universities College of Medicine. He went on to complete an emergency medicine residency at Loma Linda University. Dr. Rush also graduated from Pfeiffer University, completing an executive MBA/MHA program. He has completed physician training & certification in Age Management Medicine, jointly sponsored by The Cenegenics Education and Research Foundation (CERF) and the Foundation for Care Management (FCM). Dr. Rush has been practicing Age Management Medicine since 2009 and founded Longevity Physicians Insurance Company specifically for the practicing age management physician. Call 860.466.5307, or go to for an application. Email




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