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Missed Opportunities to Diagnose Pancreatitis

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Missed Opportunities to Diagnose Pancreatitis

Related to: Ambulatory, Communication, Diagnosis, Primary Care


Description

A 28-year-old patient was diagnosed with acute pancreatitis and irreversible kidney damage six months after she first complained of epigastric, upper abdominal, and lower chest pain.

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Key Lessons

  • Patient’s may need help understanding the “next steps” when their physician is uncertainty about a diagnosis.
  • Informal interactions with patients are rife with risk.
  • A patient’s disagreement with an inconclusive diagnosis is a red flag for formal follow-up.
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Clinical Sequence

Four months after giving birth, a 28-year-old patient presented at her physician’s office with complaints of epigastric, upper abdominal, and lower chest pain. She was seen by one of her physician’s associates, who confirmed epigastric tenderness and diagnosed gastroesophageal reflux disease, or GERD. The patient openly disagreed, saying it did not “feel like heartburn.”

 

Nonetheless, the physician prescribed ranitidine to reduce acid production. He also told the patient to make a follow-up appointment within four weeks if the pain did not subside, and that further diagnostic testing would be considered at that point.

The patient continued to experience pain, but did not make a second appointment. Two months later, when she brought her infant in for his six month visit, she sought out her primary care physician—even though she did not have an appointment. She conveyed what his colleague had diagnosed two months earlier and what medication she had been prescribed. The patient also informed him that the pain had not decreased. Her PCP wrote a prescription for another medication. He did not order any diagnostic testing.

 

Three months after that—five months after her initial complaints of discomfort— the patient returned to her primary care physician complaining of severe vomiting, diarrhea, reduced urination, and upper abdominal pain so severe that it made her cry, over the previous 24 hours. He found epigastric tenderness and administered a “GI cocktail” of Xylocaine, a local anesthetic, and Maalox. He performed no laboratory tests or radiological studies. The patient was discharged to home.

 

Later that day, the patient became so ill that she presented at a local emergency department where she was diagnosed with acute pancreatitis. She was found to have acute renal failure/anuria and irreversible kidney damage. After several months of dialysis treatments, the patient underwent a renal transplant that later failed. She is currently on dialysis.

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Allegation

The patient sued her family practitioner and his colleague for failure to recognize her renal complications.

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Disposition

After a lengthy trial, the jury deliberated for several days before reaching a verdict in favor of the physicians. Although no indemnity was paid, the defense costs were nearly $300,000.

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Analysis

  1. Missed opportunities are often crystal clear—in hindsight. In this case, the office practice did not track the patient’s compliance re: the recommended follow-up appointment. That physician (who may not have known the patient as well as her PCP) assumed she would follow through if the pain persisted. The failure to make that appointment impacted the jury’s decision, and quite possibly the patient’s health.
    Because the diagnosis (“probable GERD”) was tentative, the physician’s duty to encourage a more definitive process (i.e., testing)—and then track the patient’s compliance—was elevated. Uncertainty is part of the process, but it can leave a patient unclear on next steps. The patient would have had a good context for deciding whether to actually make, and keep, the appointment if her physician had said: “I think this is reflux, but I’m not entirely certain. Let’s try some medicine, but let’s also have a follow-up appointment already scheduled. If the symptoms disappear, you can cancel; if not, please keep the appointment.” An office system that helps patients make the follow-up appointment before they end the current visit also aids compliance.

  2. A second missed opportunity was the patient’s “drop-in” appointment with her PCP (in conjunction with her infant’s appointment). When he suggested a change in her medication, the patient may have assumed that his decision was based on more information than he had at hand. In fact, he was not prepared to see her; he did not have her record in front of him, and was unfamiliar with the details of her most recent visit with his associate, until the patient mentioned it during that informal encounter.
    Informal interactions with patients are rife with risk. A physician without the documented context from prior visits cannot do much for the patient except—as in this case—prescribe a different medication. When unscheduled contact is initiated by the patient, physicians should defer to a time (e.g., a schedule appointment) when they can devote adequate attention to the patient’s concerns. A comment such as “I would feel more confident speaking to you when I have your record in front of me and the time to focus on your questions. Let’s see when we can arrange an appointment or schedule a phone call and do this right.” lets the patient know he or she will get your full attention.

  3. Early on in this case, the patient openly disagreed with the physician’s diagnosis that her pain was caused by “heartburn.” The ultimate diagnosis proved her right, and her decision to file a lawsuit was based, in part, on a sense that the first physician did not listen to her.
    The combination of an inconclusive diagnosis and the patient’s disagreement with that assessment is a red flag for formal follow-up. Patients who experience a bad outcome may be motivated to file a law suit because—in hindsight—they feel as though nobody was listening to them. Even when the evidence cannot link their outcome to a clinician’s breach of duty, the patient is determined to be heard, and sometimes they win in court despite the medicine. When the sequence of events does demonstrate a connection between the patient’s concerns being ignored and the bad clinical outcome, the plaintiff is, indeed, likely to win and the jury is award may well reflect that personal slight.
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February 14, 2006
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