Grace Sutton was a 42-year old, African-American psychiatrist from Portland, Maine. She finished medical school at the top of the class, and she owned a well-known private practice in Manhattan.
Her clients raved about her. Grace was married to a famous patent attorney in New York, and in her free time, she enjoyed going to charity events and museum exhibitions.
She lived with her husband in a luxurious loft apartment next to Central Park, and they were planning on having a baby. It had been a few months since Grace’s last appointment with her gynecologist and she had one final visit at a gynecologist clinic before her big procedure -- in vitro fertilization.
She was meeting with Dr. Lottie Velazquez, an older woman who seemed calm and confident, and Grace found her presence comforting.
“Nice to meet you, Dr. Velazquez!” - Grace replied with a smile on her face.
Grace told Dr. Velazquez that she had been having some mild abdominal pain, but wasn’t sure of the cause - thinking perhaps it was stress related.
During the physical examination, the conversation between the two was relaxed. “So, you’re a psychiatrist, right?” Dr.
Velazquez prompted. Grace replied in a steady manner: “Yes, I am.
I think of it as mental wellness and I like to say: Your mind is your best friend.” Dr. Velazquez nodded and smiled, “I wish you could say that to my daughter.
She’s a teenager and she’s going through all sorts of things - she broke up with her boyfriend, got into a fight at school, and smokes regularly.” As the conversation continued, Dr.
Velazquez kept talking about her daughter and got so worked up that she hardly focused on the physical exam. After a few minutes, Dr.
Velazquez asked Grace to get dressed. When she walked over to the computer to enter the physical exam into the electronic medical record system, Dr.
Velazquez realized that she hadn’t done a proper physical exam so she copied the findings from a prior appointment. Copy, paste!
Dr. Velazquez told Grace that her gynecological examination was normal and that she would make a great mom one day.
Grace left the clinic feeling great. A few more months went by, and Grace arrived with her husband at the gynecologist clinic to undergo in vitro fertilization.
She had been having more severe abdominal pain, and wanted to figure out what may have been causing it. She was seen by a different gynecologist, Dr.
Rice, who did a physical exam and felt a large mass in her lower abdomen. A bedside ultrasound was done that revealed a huge abnormal growth in Grace’s uterus - a uterine fibroid.
Dr. Rice canceled the in vitro fertilization procedure until a myomectomy - removal of uterine fibroid - could be performed.
The size of the fibroid meant that it was the most likely cause of her abdominal pain, and that it was probably there even during her prior exam.
Within a week, Dr. Velazquez received a letter stating that her hospital was being sued and that she was being named for medical malpractice - specifically an inaccurate and inadequate examination.
Now - to rewind this back - let’s imagine that Dr. Velazquez wrote the examination report by herself and didn’t simply copy and paste together her final report in the Electronic Medical Record.
Even if she had been using a template, let’s say that she had carefully reviewed it and made sure that it accurately reflected her findings.
In that scenario, Dr. Velazquez would have most likely focused on doing a thorough exam and may have identified