The Best Laid Plans: Delayed Diagnosis of Colorectal Cancer

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Description

A woman in her mid-50s died from metastatic colon cancer four years after presenting to her PCP with diarrhea which was guaiac-positive.

Key Lessons

  • Busy physicians must have systems for appropriate follow through on tests ordered.
  • Maintain an active, up-to-date problem list for all patients.
  • To encourage participation in the care process, the patient must be fully informed of the issues and the risks, benefits, and alternatives to treatment.

Clinical Sequence

A 55-year-old obese woman with a history of hypertension presented to her primary care physician (PCP) with complaints of weight loss and diarrhea with mild, occasional cramps. She also complained of joint pain and was diagnosed with osteoarthritis. The PCP characterized the diarrhea as “functional;” a hemocult test in the office, however, was guaiac-positive. Her note stated that the guaiac-positive stools “raise concerns for some form of colitis, polyps, or possible malignancy.” The patient’s rectal and abdominal examination was otherwise normal. The addendum to her office note indicated that one additional stool sample tested as guaiac-positive and that “it is likely that she will need a colonoscopy.” The patient was also diagnosed with hypertension and an elevated cholesterol. In a follow-up visit with the nurse for a blood pressure check the following month, the patient indicated she was anxious regarding the blood in her stool.

The patient visited the PCP several times over the next several months, primarily for follow-up related to the hypertension, which was monitored very closely by the PCP. At no time during any of these visits was the diarrhea, the blood in the stool, or the colonoscopy discussed with the patient. When the patient was seen for a physical examination four months later, the PCP omitted the rectal examination altogether. Eight months after that, the patient presented with a complaint of right lower quadrant discomfort which had persisted for more than 10 days. On exam, the physician noted a sense of fullness in the right lower quadrant with tenderness to touch, although no mass was palpated and the stool was guaiac negative. The PCP ordered an abdominal CT scan, colonoscopy, and blood work.

The CT scan documented cecal thickening and the colonoscopy demonstrated a large ulcerated lesion in the cecum. Biopsies were positive for adenocarcinoma. The patient underwent a colectomy and the findings at the time of surgery included peritoneal metastasis. The patient subsequently underwent a year-long course of palliative chemotherapy. She died two years later.

Claim Sequence

Prior to her death, the patient filed suit against her PCP for failure to diagnose colon cancer.

Disposition

The case was settled in the high range (>$500,000).

Analysis

  1. In her initial office note, the patient’s PCP specifically documents that the patient had blood in her stool. She sent out two additional stool samples for testing and she noted that the patient most likely needed a colonoscopy. After this note, there was no further documentation regarding the additional tests or the colonoscopy. During her deposition testimony, the PCP stated that her plan was to order a colonoscopy if there were additional guaiac-positive stool samples. Despite the notations in her record, there is no documentation regarding the additional stool tests or the colonoscopy.
    The PCP failed to have any system or mechanism in place to ensure proper follow-up for her patient. Busy physicians must have systems for appropriate follow through on tests ordered to ensure that results have been reviewed in a timely fashion and additional testing ordered accordingly. Based on the standard of care, a colonoscopy should have been ordered for this patient at the time of the initial visit. Although the doctor contemplated ordering the colonoscopy, she had no reminder system in place to ensure that she assessed the need for the colonoscopy after the additional test results were returned.

  2. Although the physician’s office notes were complete, she failed to maintain an ongoing problem list. The PCP diligently followed the patient’s hypertension, but lost sight of other critical issues for the patient. Documentation in subsequent visits demonstrated that the PCP did no further assessment associated with the diarrhea, guaiac-positive stool, or the need for the colonoscopy. For the patient’s annual physical exam, the rectal exam was omitted.
    In a primary care office practice, it is critical that the PCP maintain an active, up-to-date problem list for all patients. Such a list provides a quick and accessible review of major problems and serves as a reminder to the physician of other issues that warrant follow-up during other office visits, whether or not related to the purpose of the visit.

  3. The PCP’s office notes do not summarize or document any conversations and/or advice the physician provided to her patient regarding the guaiac-positive stool tests. During her deposition, the patient testified that the physician did not discuss the tests with her and did not explain the importance of follow-up or the need for colonoscopy.
    Educating and providing information to patients is essential in the practice of medicine. In this instance, it was critical to the patient’s health that she fully understood the potential consequences of blood in the stool and what follow-up tests may be necessary to ensure all the proper steps have been taken. To encourage the patient to participate in the care process and take responsibility for his/her health care, the patient must be fully informed of the issues and the risks, benefits and alternatives to treatment. In the event a patient fails to follow up with suggested testing or referrals, documentation of the advice to the patient is crucial for both better care of the patient and to the defense of any potential case. Such defense is further bolstered by the physician’s documented reminders and follow-up with patients who fail to keep appointments for tests or referrals. Any outreach telephone calls or letters to the patient must be documented in the medical record.

Kim Nelson, R.N., J.D. Kim Nelson is General Counsel for Harvard Vanguard Medical Associates, Inc. for Forum, July 2002