Narrow Focus Obscures Cancer Diagnosis

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Description

A 48-year-old man complained to his primary care provider for two and a half years of a non healing skin lesion on his penis that was later found to be squamous cell cancer.

Key Lessons

  • Patient's multiple complaints were not properly addressed.
  • Documented inappropriate communication by the PCP.
  • Physician unable to establish a differential diagnosis.

Clinical Sequence

In January 2002, a 48-year-old-patient was seen by his primary care physician (PCP) of 12 years, for a sprained wrist. His medical history included a puncture wound to his right thigh (1983), bypass surgery (1999), and placement of a cardiac catheter (2001). During the visit, the patient mentioned an itchy rash on his penis. The PCP gave it a quick look, prescribed Lotrimin and Hydrocortisone, and asked the patient to call if the condition did not improve.

In May 2003, the patient called the PCP's office and spoke to an RN concerning a year-long rash in his groin area. He reported that a variety of OTC treatments only provided temporary relief. In response to the call, the PCP noted in the patient's record asking the RN to call the patient back with instructions to try Spectazole: she also wrote "It returns because he works out every day…cannot cure with this level of activity."

In August 2003, the patient called the PCP's office to complain that the Spectazole cream was not working and that he would like to try something else. The PCP recommended Lotrimin and requested a routine follow-up appointment later in the week.

Two days later the patient returned for his follow-up appointment. The PCP noted that the rash had moderately improved, but a thickened patch of skin remained over the shaft of his penis. It looked fungal and appeared to be irritated from scratching. The PCP informally discussed the case with a dermatologist in a nearby office, but her colleague did not examine the patient. They decided to a try combination of samples of Loprox and Lidex. The patient was told to call back for a prescription if it worked. A week later, he called for a prescription.

In early January 2004, the patient called again, complaining that the prescription was now not working and requested a referral to a dermatologist. In the patient's record, the PCP wrote: "IT WON'T GO AWAY UNLESS HE STOPS WORKING OUT. IT IS A FUNGUS. LIVE WITH IT AND CREAM WILL KEEP IT IN CHECK." She told the patient that dermatology would say the same thing, and declined the referral request.

Two and a half months after that, the patient was seen at the office for a complaint of sciatica. He was also treated with Lidex ointment, and Diflucan for the persistent penile rash. At the time of this visit, the patient had stopped his exercise routine due to his cardiac health.

In July 2004 the patient changed providers. His new physician documented a long history of an irritated penile rash, with a red raised lesion, unresponsive to yeast and steroid treatments. This PCP referred the patient to dermatology, and prescribed Ketoconazole and hydrocortisone cream twice a day. Three months later, the patient was seen by a dermatologist who diagnosed dermatitis of the penile shaft and prescribed Aclovate cream and Zeasorb powder with instructions to follow up in two weeks.

During the follow-up appointment, in October 2004, the dermatologist biopsied the lesion on the penis, which led to a diagnosis of squamous cell cancer.

Allegation

A suit was filed against the first primary care physician, alleging a delay in diagnosis of squamous cell cancer of the penis, resulting in permanent loss of sexual function.

Disposition

Following three non-supportive expert reviews and an unsuccessful Tribunal finding, the case was settled in the high range.

Hyperlinks

  1. Telephone
  2. Documentation

Analysis

Clinical Perspective

  1. The consistency of the patient's symptoms and complaints didn't justify a change in the differential diagnosis.

    Throughout the record, the patient's rash is referred to as: a fungal infection, yeast infection, atopic dermatitis, contact dermatitis, and "a rash of unknown etiology." These assumptions often continued without further physical examination and despite the fact that the prescribed treatments failed to improve the condition. Ongoing complaints unresolved by standard treatment necessitate a broadening of the diagnostic focus.

  2. The patient seemed satisfied with having his complaints triaged by a RN through telephone encounters.

    Telephone calls should not be equated with a live visit, but they are a common component of office practice-and a common aspect of diagnosis-related malpractice claims. One of the most significant ways a practice can improve telephone care and reduce liability, is to focus on how repeat calls are managed. Consider implementing the "second call / third call" rule: after a second call for the same problem, a physician should be consulted or speak directly with the patient; after a third call for a persisting or worsening problem, the patient should be seen.

Patient Perspective

  1. My request for a referral to dermatology was denied.

    Three physician reviewers said that, after six months, when various therapeutic trials had failed, the standard of care would have been to refer the patient to a dermatologist. The patient, based on his PCP's statement that "dermatology would have the same diagnosis" thought he would have to pay out of pocket for a non-referred dermatology appointment. A detailed discussion between the PCP and the patient about this option may have expedited the referral.

  2. My rash was not properly addressed despite multiple complaints.

    Skin lesions of unknown origin should either be followed to complete healing in the case of therapeutic trials or biopsied. Patients rightly expect sequential physical examinations. Telling the patient to "live with" the rash is not appropriate.

  3. My physician's recommendations did not address my complete medical history.

    The PCP advised him to stop working out so the rash would go away. This conflicted with the recommendations the patient received to continue exercising to counter his coronary artery disease.

Risk Management Perspective

  1. A curbside consult may not have been appropriate.

    Simple problems that can be answered without considering too many variables are well-suited for informal consultations. However, complex issues that require deeper investigation are better-suited to formal consultation. A formal consultation to dermatology would have been appropriate, since the diagnosis was unproved and it failed to clear up fully with therapeutic trials.

  2. Communication is difficult when dealing with a difficult situation.

    For many clinicians, "success" is equated with effective clinical problem solving or a "cure." They may feel that the patient is pointing the finger at them for the lack of progress. One result can be a subtle urge to view the patient as the problem. On the other hand, patients may become depressed, angry, or demanding when treatment does not work or if they perceive that the clinician is blaming them for their illness. Together, these frustrations and blaming attitudes can contribute to mutual dissatisfaction. Clinicians should be aware of this potential, and ensure that their words and actions do not reinforce the wrong attitude.

  3. The documentation in the record was incomplete and inappropriate.

    Except for one entry, over nearly three years of documentation, is the lesion described in any way: no descriptions of color, friability, wetness/dryness, depth, shape, or other dimensions. Ideally, the record should offer detailed and updated descriptions and, when appropriate, photo documentation.

Legal Defense Perspective

  1. Settlement was, in part, driven by the number of complaints and the denial of a dermatology referral.

    Jurors and arbitrators empathize with patients whose complaints seem to fall on deaf ears.