Description

A 62-year-old woman with a family history of colon cancer and history of abdominal pain, anemia and weight loss was not offered colon cancer screening before she developed metastatic colon cancer and died.

Key Lessons

Primary care physicians should universally offer appropriate health screening per age, gender, and risk factors, and document any patient refusal.
Physicians cannot assume that a patient will refuse recommended screening.
Extend and document outreach for patients who fail to keep scheduled examinations.
Practice-based systems are vital to facilitate continuity of care and promote documentation.

Clinical Sequence

A 62-year-old female patient presented in March 1996 to her long-time PCP with complaints of blood in her stool. A guaiac test in the office was negative. Her past medical history included hypertension, arthritis, peptic ulcer disease, obesity, and coronary artery disease. She had never received colorectal cancer screening. Based on a 20-year relationship that included frequently missed appointments, the physician believed she would refuse screening tests for colorectal cancer.

She returned in June with a complaint of abdominal pain. The physician prescribed an H2 blocker, Zantac, and noted a plan to obtain a right upper quadrant ultrasound if there was no improvement in her symptoms. The record does not indicate that a stool guaiac was obtained at that exam or if the patient was still reporting blood in her stool.

Failing to keep the next two appointments, the patient presented in August of the same year with improvement of her abdominal pain on Zantac and a stable weight. The patient was not anemic, and a CEA was within normal limits.

During the next two years the patient was seen for chest, abdominal and back pain, as well as hypertension She was treated with Biaxin and Prilosec for presumptive H. Pylori. Documentation was minimal in the visit notes, with no evidence of a comprehensive examination during this period or the years prior.

A visit on May 13, 1999 included a comprehensive examination. The physician noted a nine-pound weight loss, and a review of systems, including gastrointestinal and urinary, that he characterized as negative “in general.” Documentation does not include family history, although subsequent legal investigation revealed that the patient’s sister had died of colon and lung cancer in 1995. The patient had a pelvic exam during this visit, yet there is no documentation that a rectal examination was performed. Subsequently the patient had a screening mammogram. Lab results included low MCV/MCH; hemoglobin was 12.1, and hematocrit was 37 percent, both on the low end of the normal range and decreased somewhat from previous measures. Recommendations on the lab sheet suggest follow up to include additional hemoglobin and stool tests. However, the record does not indicate that this information was ever communicated to the patient.

The patient next presented to the practice four months later, on September 9, 1999, with complaints of a tooth infection. Care included assessment of her oral cavity, tooth, lungs and extremities. Follow up included a dental appointment and an appointment with her physician, which she did not keep. There is no evidence that the NP addressed the recommendations in the lab report from four months prior, including follow-up hemoglobin and stool tests.

In November, the patient went to the ED complaining of chest and abdominal pain. Chest X-ray was positive for pulmonary nodules and suggestive of metastatic disease. She died from metastatic colorectal cancer a month later.

Allegation

The patient’s children sued both the PCP and the medical group, alleging failure to provide proper screening and testing, resulting in a delay in diagnosing colon cancer.

Disposition

The case was settled in the high range ($500,000 to $999,999)

Analysis

Clinical Perspective

The patient did not receive colorectal cancer screening appropriate to her risk, based on age, presentation, or family history. Current guidelines from CRICO/RMF and national organizations recommend that everyone over the age of 50 receive some type of screening for colorectal cancer. Options for asymptomatic patients include colonoscopy every 10 years, annual fecal occult blood test (FOBT), flexible sigmoidoscopy every five years, barium enema every five years, and some combinations of those. Patients with symptoms, such as anemia, weight loss, or rectal bleeding should be referred to a specialist for a complete diagnostic workup. A single FOBT in the office alone does not qualify as a diagnostic workup nor adequate screening.
The physician did not know the patient’s sister died of colon cancer during their 20-year relationship, and a family history was not documented.
Family history should be updated annually, as it is subject to change and may affect cancer and disease screening. The use of a questionnaire or prompt on an exam template can facilitate this process. Patients who refuse or are unable to complete the questionnaire should have an oral review of risk factors, including family history, and notes about the conversation should be put in the medical record.

Patient Perspective

The patient was not approached about a colon cancer screening test. The physician’s long term relationship with the patient and her history of missed appointments resulted in his making assumptions of her probable refusal for an FOBT series or a colonoscopy, although she had been willing to undergo cervical and breast cancer screening.
A long term relationship between patient and physician is a usually positive attribute and patients often take very seriously the recommendations of a trusted doctor. Knowing a patient very well can lull a clinician into a lack of objectivity. Willingness to undergo other screening tests can suggest willingness to undergo colorectal cancer screening. Regardless of the patient/ physician relationship, all diagnostic and screening tests should be reviewed with the patient. Counseling, education and physician recommendations along with patient response including deferral or refusal should be documented in the medical record.

Risk Management Perspective

This was a non-compliant patient, who missed many appointments and requests to follow-up over 20 years.
Patients who routinely fail to keep appointments are at risk for “loss to follow-up” The physician should be made aware of patients who fail to keep an appointment or repeatedly cancel appointments so that he/she can review the record and initiate appropriate outreach. All outreach efforts should be documented in the medical record.
The patient was not notified of the need for follow up testing for August 1999 blood work when she returned to the practice for episodic care in September. Lack of office practice processes to ensure continuity resulted in failure to follow up on an abnormal test result, even when the patient is in the office with another complaint.
Recommendations for follow up should be prominently displayed in the medical record either on the problem list, or in the MD notes. Providers should routinely review documentation of previous visits before evaluating a patient with an episodic concern, and ongoing problems should be addressed with the patient at that time.

Legal Defense Perspective

Scant documentation with illegible components made it difficult to determine whether there was appropriate patient assessment and appropriate clinical rationales.
Difficulty in deciphering notes and minimal documentation impedes the ability to defend a claim. Lack of documentation of a family history and evidence of discussion of colorectal screening pose obstacles for the defense. Standard templates including patient questionnaires and physical examination forms with prompts for age and gender appropriate health screening and counseling can encourage appropriate documentation.

Not Offered Screening Test Before Colorectal Cancer