Description

A 64-year-old-woman was diagnosed with metastatic colorectal cancer after receiving care from both a primary care provider and gynecologist that did not include colorectal screening.

Key Lessons

Lack of communication between providers caring for the same patient can result in failure to obtain health screening and a delay in diagnosis.
Providers need to confirm previous screening efforts and review results, even with educated and motivated patients who present as excellent historians.
Even when patients may see their PCPs less frequently than they see a specialist, the PCP is usually considered ultimately responsible for health screening.

Clinical Sequence

A 64-year-old woman, with no family history of colon cancer, called her PCP with complaints of bright red rectal bleeding and discomfort. She was immediately referred to a gastroenterologist and diagnosed with colon cancer. At issue is whether, during the nine years prior to presentation, she should have been offered colorectal screening and evaluated for vague, but persistent, abdominal complaints.

During the 15 years that the patient was under the care of a previous gynecologist, she underwent a barium enema for a complaint of a “pulling sensation” in her right lower quadrant. The test was normal. She later had a guaiac positive stool, and a GI evaluation was recommended in the note, but no mention of referral or follow up with GI was documented. Just before her gynecologist retired, the patient again complained of “a pulling sensation” in her right lower quadrant. A rectal/vaginal examination was documented as normal.

The patient first visited her new gynecologist at age 58, and records were provided when the care was transferred. The patient selected a primary care provider at the same time. and began a series of annual exams with each doctor. Two years later, the patient first complained to the gynecologist of “a pulling sensation for past two years.” The patient related that her previous gynecologist thought it was a GI issue. She was assessed as an intelligent, organized, and responsible patient who was vigilant about annual appointments, Pap smears and breast cancer screening. The new gynecologist believed she would follow up with her PCP, though there is no documentation of either communication with the PCP or a referral to GI for the issue.

Allegation

The patient sued both the gynecologist and the PCP, alleging failure to appropriately screen for and diagnose colon cancer.

Disposition

This case was settled against the primary care physician in the high range. The case against the gynecologist was dismissed.

Hyperlinks

Analysis

Clinical Perspective

The patient did not receive the standard of care for colorectal screening at the time, which falls under the purview of the PCP.
Colorectal screening for asymptomatic patients over age 50 included annual rectal exams and stool occult blood tests followed by a flexible sigmoidoscopy every five years. A review of a new patient’s screening records, and a solicitation of family history is part of an appropriate assessment for screening.
The gynecologist failed to adequately follow up on a recurring GI complaint.
For a patient with unresolved GI symptoms, referral to a gastroenterologist is expected. Current recommendations for some GI symptoms include visualization of the colon if not done in the previous two years. Gynecologists in the role of specialists should communicate clinical concerns outside their scope of practice to the patient’s PCP. This allows the PCP to coordinate care and monitor follow-up. Closure is ensured by reviewing resolution of this complaint with the patient at his or her next visit.

Patient Perspective

The patient held her gynecologist, rather than her PCP, accountable for failure to alert her to colorectal screening and the resulting delay in diagnosis, bringing the gynecologist into the lawsuit.
Colorectal screening is potentially confusing to patients. Gynecologists perform rectal examinations in order to palpate the ovaries, and patients may infer that colorectal screening has been provided. Since the majority of women’s health check-ups are linked to the annual gynecology examination, women may identify their gynecologist as responsible for providing all health screening. Specialists should clarify their role in the patient’s care and encourage the patient to establish a relationship with a PCP.
Although the patient inaccurately reported her screening history, she felt betrayed, as she was vigilant in seeking preventive health care and would have undergone appropriate screening if advised to do so.
Lay persons may not understand medical terminology. Soliciting relevant information from patients may require “defining” key terminology when gathering personal and family history. Counseling should include an explanation of the screening tests available to assist patients in taking an active and accountable role in preventive care. Reviewing age appropriate health screening practices and establishing the PCP’s role in providing colorectal screening will minimize confusion.

Risk Management Perspective

Reliance on the patient to transmit the gynecologist’s recommendation for a GI work up, combined with a lack of direct communication between the gynecologist and the PCP, contributed to a delay in diagnosis.
Patients who appear competent and diligent may still fail to follow through. Specialists who are presented with worrisome symptoms outside their area of expertise should notify the patient’s PCP regarding the patient’s symptoms—properly handing off the issue to the appropriate provider.
The PCP did not review the new patient’s prior records for cancer screening.
Lack of review of symptoms, confirmation of previous screens, and failure to offer screening and/or appropriate follow-up leaves PCPs open to the allegation of delay in diagnosis. Documentation of a personal and family history, review of systems, and confirmation that age and gender-appropriate colorectal screening was offered and completed will help mitigated this risk.

Legal Defense Perspective

Lack of documentation that the PCP reviewed previous GI tests contributed to the inability to defend the case.
Following discussion of a previous work-up, a PCP should attempt to obtain test results. Review of a patient’s personal and family medical history, review of symptoms, and efforts to clarify and validate when tests are reportedly performed are important elements of patient assessment that must be documented.
The PCP, not the gynecologist, was ultimately held responsible for failure to offer colorectal screening.
Patients may feel a certain provider is responsible for an adverse outcome and include that provider in the lawsuit. However, the legal system may assign liability to another named clinician entirely, based on the standard of care. Although gynecologists will encourage patients to obtain reproductive health screens, experts hold the PCP responsible for ensuring colorectal screening.