Case Study
A 58-year-old male went to see his physician in January 2015 for a physical exam. He had a history of hypertension and hyperlipidemia controlled on an ACE inhibitor and a statin. On review of systems, the patient complained of bright red blood per rectum when he had a bowel movement. The physical exam was unremarkable, and the patient’s stool guaiac was negative. The office visit notes suggested a gastrointestinal referral was planned for a colonoscopy. There was no separate referral form or distinct electronic referral communication for the colonoscopy. Three days after the visit, the patient’s lab tests were unremarkable except for a mild anemia, (HCT of 36). At the time of reviewing the labs, the physician did not act on the anemia because he remembered that a colonoscopy had been ordered at the time of the appointment.
The patient returned twice over the next year and a half for respiratory infections and allergies. The colonoscopy, bleeding, and anemia were never mentioned in any of these visits, nor were they noted in a problem list. In July 2016, the patient presented to the ER with abdominal pain, fever, nausea, and vomiting. He was admitted and underwent an exploratory laparotomy which revealed widespread cancer of the colon. He was eventually found to have stage IV cancer and was treated with chemotherapy but expired six months later. His surviving family filed a lawsuit.
Although the physician had the correct plan, it was not properly executed. The fact that there were several follow-up visits where the findings of anemia and bleeding were not discussed makes the care difficult to defend. The physician did routinely update problem lists in medical records which also made the course of care challenging to find a credible witness to support.
An up-to-date problem list, ideally updated in real time, allows one to not have to rely on memory alone to address worrisome issues. The problem list was originally created by Lawrence Weed in the 1960s as part of his innovation around problem-oriented records. A simple idea, the problem list soon became a commonly accepted part of the medical record and is used in most medical records today. In the office, the problem list helps practitioners identify the most important health factors for each patient and provides a convenient checklist of care plans.
Finally, there is an issue around communication with the patient. Even without putting the issues of hematochezia and anemia in the problem list, if the physician had clearly explained the risk and concerns he had about the possibility of cancer and documented this conversation, then some of the responsibility would have been on the patient. A reasonable patient told that they might have cancer could be expected to demand more workup. However, in this case, the lack of documentation of any such discussion adds to the weaknesses in the care.
Failure to Diagnose Can Be Reduced with Updated Problem Lists
Failure to diagnose or delay in diagnosis is the major cause for a lawsuit against a primary care physician. High-risk areas include heads (neurologic events, CVAs, and meningitis), hearts (the triple rule out), guts (missed appendicitis, ischemic bowel, etc.), severe infectious diseases, and cancer. Colon cancer is currently one of the most common causes for “delayed diagnosis of cancer” litigation followed by breast, prostate, lung, and melanoma. Although lack of screening can sometimes be the cause of a lawsuit, it is most often the failure to diagnose in a symptomatic patient.
Lessons Learned
In this case study, there was an initial system failure in not setting up an important test and workup. This was compounded by a failure to place the active problems in a problem list. There were multiple chances and visits where the physician could have corrected the original miss. Being meticulous about updating and utilizing a problem list could have helped catch this cancer at an earlier, possibly curable stage and also have prevented a lawsuit.
Information in this article is for general educational purposes and is not intended to establish practice guidelines or provide legal advice.
Article originally published in 2Q24 Copiscope.
