Missed Follow-up, Missed Cancer

Description

A 36-year-old male smoker was diagnosed with asthmatic bronchitis after complaining of chest congestion and coughing up blood, six months before being diagnosed with fatal lung cancer.

Key Lessons

Reoccurring symptoms should be followed until a resolution or a diagnosis has been made.
Patients need information in order to be engaged in following unresolved symptoms.
Practices should have a reliable system to contact patients who do not keep appointments or who have outstanding test results.
Physicians are responsible for supervising nurse practitioners in their practice.

Clinical Sequence

A 36-year-old male with a history of smoking (2-4 packs of cigarettes per day), called his PCP’s office with complaints of chest congestion and coughing up small clots of blood for the previous few weeks. He spoke with a nurse practitioner (NP). The PCP prescribed antibiotics and the NP asked the patient to call back if he did not feel better.

A week later, the patient saw the same NP in the office for shortness of breath and wheezing. This time he did not mention coughing up blood. A chest X-ray was read as normal by a staff radiologist. The NP shared the findings with the patient, diagnosed asthmatic bronchitis, and prescribed a second course of antibiotics and asthma inhalers. The patient was told to return 48 hours later to be reexamined.

The patient did not return in two days as instructed. Instead, he returned to the practice a month later, complaining that he had coughed up blood for the last two days. An X-ray taken that day was interpreted by a staff radiologist as showing signs of infiltrate in the right lobe; however, the radiologist considered this to be unchanged from the X-ray taken a month earlier. The PCP believed the infiltrate was smoking-related. The patient received prescriptions for steroids and a different antibiotic, was told to return in seven days, and was encouraged to stop smoking.

A week later, the patient’s lungs showed marked improvement. He was advised to finish his antibiotics and continue with the inhalers. Within a week, however, he went to the emergency room with complaints of shooting pain in his right lung and difficulty breathing. A new X-ray showed continued signs of infiltrate in the right lobe. A TB test was done, and the patient was instructed to return to his PCP to go over his TB test results. His PCP’s office reminded the patient the next day with a phone call and made an appointment for the following week, but he failed to return.

Nearly three months later, the patient called his PCP, complaining of a “golf ball” size lump on his neck and an unusual taste in his mouth. The patient was seen the following day, and his PCP diagnosed a swollen lymph node. He prescribed antibiotics and referred the patient to an ENT, who saw him within three days. The ENT changed his medication to Augmentin and scheduled a follow-up visit for three weeks later. At that time, he reported that after initial improvement in the mass with Augmentin, it had returned to its original size once he finished the medication.

One month later, during a scheduled follow-up visit, a biopsy of the lump suggested malignant neoplasm. The patient underwent a CT scan, MRI, and an additional fine needle biopsy. The ENT specialist notified him by phone with a diagnosis of stage IV lung cancer with metastasis to the brain. The patient died the following year.

Allegation

The patient sued his primary care physician, claiming a six-month delay in diagnosis and treatment of lung cancer.

Disposition

Following a successful tribunal finding for the plaintiff, the case went to arbitration and was decided in favor of the defense.

Analysis

Clinical Perspective

Hemoptysis and unexplained pulmonary infiltrates require a definitive diagnosis.
A patient’s age can mislead a clinician facing symptoms of undefined origin. Certain presentations are more worrisome than others and should be explored until a definitive diagnosis is made, even if a suspected condition is unlikely in a 36-year-old man. Providers should consider the seriousness of the worst likely outcome when considering problems that don’t have a clear source. This is a factor in deciding on possible follow-up tests to address the symptoms and monitor the patient’s status, and should be explored until a definitive diagnosis is made even.
A timely diagnosis was hampered because the patient did not always return as instructed.
Office practices need to develop systems to close the loop on “no-show” patients. Depending on the potential seriousness of the symptoms, a phone call or written reminder may be appropriate. A reminder system for reasonable follow-up on unresolved problems increases the opportunity to do additional tests, identify the source, and treat the problem successfully.

Patient Perspective

Did the patient appreciate the seriousness of following his PCP’s instructions?
In order for patients to be encouraged to participate in the care process and take responsibility for their health care, they must be fully informed of the issues as well as the risks, benefits, and alternatives to treatment. When 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 the defense of the case.
The ENT told the patient over the phone that he had been diagnosed with lung cancer.
This type of bad news should be delivered in person, by the provider closest to the patient. If the patient has a close friend or family member involved in his or her care, suggest they come too to help understand the information. Tailor the discussion to the patient's level of sophistication, but do not assume the extent of the patient's knowledge. Probe for a sense of the understanding during the conversation. The patient may not hear much after the initial bad news. Provide summary information that the patient can review later.
The plaintiff argued that the Nurse Practitioner was improperly supervised.
Some patients prefer care by a physician and may question the abilities and oversight of an advanced practice nurse or physician extender. Patients need to be told of the physician’s involvement in the care provided by these junior colleagues. NPs must practice in accordance with written guidelines developed in collaboration with the individual physician and nursing administrative staff. These guidelines should address the questions on how best to serve patients under the combined care of physicians and nurses, emphasizing a team approach. Regular review of these guidelines and a regular conference/chart review time to review clinical care is an important part of maintaining quality patient care in a collaborative practice.

Risk Management Perspective

The plaintiff missed numerous appointments that were scheduled for follow up.
Practices are responsible to make a reasonable effort to contact patients who miss scheduled appointments or tests. The reasonableness of the effort depends on the clinical importance of the test or visit, the severity of the patient's medical condition, and the risk associated with the missed appointment. Document your attempts to obtain follow-up, as well as missed appointments, failure to follow care instructions, and any other examples of patient non-adherence.

Legal Defense Perspective

The defense won this case at arbitration, based on the underlying fact that a six-month delay in diagnosis would not have changed the outcome.
It is difficult to prevail in court with only a so-called “causation defense,” that is, an argument that even if the care was negligent, it did nothing to change the outcome. But it is more likely to succeed, when the facts are clear. The defense called two expert witnesses, one to speak to the standard of care, and the other to address the issue of causation. The judge ultimately agreed with the defense that finding the cancer six months earlier would not have made a difference, since this particular type of cancer moves quickly and can go undetected until it is too late.