The following case abstract is from closed malpractice claims in the Harvard medical system. Some details have been changed to mask identities.
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Commentator: Carla Ford, MD
The patient had an initial physical exam with her PCP at 38 years old. Her doctor noted a normal breast exam, and recommendations for a screening mammogram and colonoscopy due to family history of colon cancer. A mammogram was never done, although the patient returned to this physician practice a dozen times over the next several years for episodic care. Six years after the initial physical, she came for a sick visit with a complaint of a lump in her breast of three weeks duration. Studies confirmed Stage 3 breast cancer, followed by surgery, chemotherapy and radiation with significant complications. The patient sued her PCP for negligent delay in diagnosis of her breast cancer; the case went to trial and the jury found for the defense.
To discuss the risk management and patient safety issues in this case, we are joined now by Dr. Carla Ford. Dr. Ford reviews professional liability claims for CRICO, Harvard’s malpractice insurance and patient safety company.
Q) Carla, most physicians would think this is unfair and unreasonable—the recommendation was made for the test, and the patient didn’t follow through. But this doctor still had to go through the trauma of a lawsuit, even with an eventual defense verdict. It doesn’t seem like sitting back and saying “it’s up to the patient for these screens” is a working philosophy in the real world, unfortunately.
A) Well, Tom, unfortunately, that’s true. Lawsuits don’t have to be fair. In this particular case, the patient had been seen for a physical many years prior to the development of cancer and had had the appropriate recommendations. Now, as a primary provider, and I practiced for many years as an internal medicine primary care provider, you really feel that your responsibility is to inform the patient at the time of a complete physical about screening tests, and that focused visits or sick visits are a different issue. Unfortunately, as you look back over your career, it’s not always the cases that you’re concerned about as a clinician that come back in a lawsuit. Often clinicians are sort of broad-sided by the cases that they do get called on…it’s really hard.
Q) A big issue seems to be the distinction between a well visit or a physical, and sick visits that are episodic and patients don’t always see the difference.
A) Yes, that’s definitely true. The problem in this particular case is that the patient was seen a large number of times, once for a car accident, once for a urinary tract infection, for bronchitis, and so there a variety of issues that were being addressed and she was someone who was active in the practice. And so one could see from her point of view that she was being seen a lot, and she might have thought, well, my doctor’s aware of all these issues. On the other hand, we know that there are so many screening tests that are recommended by the preventative task force. Recommendations are in excess of several dozen screening recommendations now, so it’s not reasonable for the physician to be thinking about those at every visit, especially visits that may just be for a sore throat or for a cough. So there is, in the mind of the provider, a very big difference between a complete physical or a time when you reassess all the issues of someone's health, and a sick visit. But, unfortunately, patients don’t always understand that distinction and they feel that the doctor should be aware of all their problems all the time.
Q) If a practice wants to intensify their patient education and their own systems to make sure that cancer screenings occur—because we know that cancer diagnosis is one of the top problems; when we have diagnosis cases they are most typically cancer—what are some of the basics, any suggestions you might have for upping our game?
A) Well, I think the most important thing in terms of cancer screening at first is to identify your patients who are at the highest risk. And one that that we see very routinely is a failure to take a family history or a failure to update it. This is one of the most common parts of a note that is just cut-and-pasted from time to time, and so lack of an adequate family history makes it difficult to identify your patients who are at risk. Having identified at-risk patients or understanding that they need routine screening, it’s important to document that you ordered those tests. For instance, if you see someone for a physical and you recommend a mammogram it's important to actually order the mammogram so that there is that documentation that not only did you suggest it but that you took the next step of ordering it. Then, if the patient fails to schedule it, that is more evidence of their lack of follow-through or lack of responsibility. I think more and more radiology departments are starting to call patients to schedule tests that have not been scheduled in order to close the loop on performance of the test, and then if a patient fails to come to the appointment then that is an additional level of responsibility that they take on. It's anything that you can do to document that you made the recommendation and that you took a reasonable effort to see that the place took place is really helpful to the defense and just good medicine.
Q) So, we see a lot of activity now with whole systems, whole hospital and healthcare systems trying to develop electronic medical records that will talk to each other and follow these orders and follow these patients, whether or not they went, and get back to the patient and the doctor. Is the electronic medical record going to be the solution for all of this? What else would you suggest?
A) Well, certainly electronic health records are a great way of maintaining an active problem list, and so there are ways to make a notation that something has been ordered and then have the computer essentially kick out a list of patients for whom that order hasn’t been satisfied. Whereas people used to keep sort of a handwritten tickler list of things to do, a to-do list, the computer of course is much more accurate at that and can monitor larger numbers of tests. So I think that electronic records can be a very big improvement in closing the loop on tests that have been ordered to be sure they are performed, and then that the test results are acted upon.
Q) What do you do about patients who just don't come in for physicals?
A) Well, Tom, unfortunately there are some patients for whom there are real barriers to booking a physical and completing that. There are some insurance plans that don’t cover preventative care. There are patients who have so many active problems that just the sheer burden of the number of appointments they need to make makes it difficult for them to add another, what they see as an extra appointment. I think most providers know which of their patients are in that situation, and if that appears to be chronically the case it would be good to remind those patients at sick visits about things like mammography. Again, it’s not really fair to the provider to take on that burden, but there are some patients who really cannot come in for physicals and will not do it, and they need screening as well.
Q) Thank you, Dr. Carla Ford, internist and consulting physician for CRICO. I’m Tom Augello.
About the series
Even in the safest healthcare setting, things can go wrong. For more than 40 years, CRICO has analyzed MPL cases from the Harvard medical community. Join our experts as they unpack what occurred and the lessons learned for safer patient care from the causes of these errors.