Description

After eight months of intermittent abdominal pain and rectal bleeding, a 62-year-old male patient died following emergency surgery that revealed advanced colorectal cancer.

Key Lessons

Vigilant follow up of a documented recommendation for testing protects both patient and clinician.
Unresolved complaints may require additional attention even when the patient is not fully compliant.
Review (clinical) patient phone calls that do not lead to an office visit.

Clinical Sequence

In early March, six weeks after an unremarkable physical exam by a prior physician, a 62-year-old male truck driver saw his new primary care physician (PCP) for complaints of rectal bleeding. The patient, who had no record of any colorectcal cancer screening, reported no prior history of occult blood, and no family history of colorectal cancer. After a rectal exam showed blood, the PCP diagnosed it as -most likely hemorrhoidal.” He prescribed Citrucel and suppositories for hemorrhoid relief and documented that the patient would need imaging of some kind in the near future. The PCP instructed the patient to follow up in two weeks, and advised that a colonoscopy should be scheduled. No follow up appointment or imaging took place.

In May, the patient called the office for complaint of bloating and abdominal pain. The nurse he spoke to recommended that he alter his diet; no appointment with the PCP was requested or offered. In July, the patient again called the office with a complaint of abdominal discomfort, but did not make an appointment with his PCP. The PCP was unaware of the phone call.

In late November, the patient presented to the Emergency Department (ED) with anorexia, abdominal pain, and nausea (his stool was negative for blood). A physician assistant diagnosed a partial intestinal obstruction and discharged the patient with Pepcid for GERD. Three days later, the patient retuned to the ED in severe, persistent abdominal pain and was rushed to surgery for a presumed bowel obstruction. The patient died two days after the surgery, which revealed advance colorectal cancer.

Allegation

Patient's estate alleged that the PCP failed to timely diagnose and treat patient's colon cancer.

Disposition

The plaintiff subsequently discontinued pursuit of the case, and it was dismissed.

Analysis

The named PCP’s confidence that his care met the standard was reinforced by the plaintiff’s abandoning the lawsuit.
Often, the initiation of a malpractice claim or suit derives from a poorly informed plaintiff seeking legal recourse to get the -real story.” When the facts overwhelmingly support the care rendered, further pursuit is unnecessary. Regardless of the outcome, virtually every allegation of medical negligence exposes opportunities for practice improvements that might help the defendants and their colleagues later avoid similar allegations. In other words, a dismissed case should not be summarily dismissed as frivolous.
A symptomatic 62-year-old patient with no prior colorectal screening was advised to schedule a colonoscopy. That recommendation was noted in the record, but neither the patient nor the PCP followed up.
Documentation is an important step in vigilant follow-up but, often, good health care has to be more active. For patients who require more avid encouragement, the clinical staff may need to 1) pose and answer questions about the need for testing and/or the patient’s reticence, 2) make the test appointment while the patient is still present, and 3) make a pre-test reminder phone call, or send an e-mail.
Although the patient did not pursue a physician appointment at the time of his May and July phone calls, his family’s lawsuit contended that his multiple complaints (i.e., phone calls), should have alerted the PCP to the severity of his illness, but they were not even brought to his attention.
Each practice establishes the guidelines and thresholds for responding to patient phone calls. When those protocols are reasonable, consistent, and include thorough documentation, the practice can function safely, efficiently and the care rendered is defendable.