A 46-year-old female died from ovarian and metastatic colon cancer two years after presenting to her PCP with a five-week history of constipation and rectal bleeding—symptoms that continued across several visits over a year and a half before she was diagnosed.
- A narrow diagnostic focus can contribute to delay in ordering necessary tests.
- Using algorithms, guidelines, decision, or support tools can lead to a more timely colon visualization or referral.
- Specialty practices need scheduling systems that take into account patients with active complaints.
- Top-quality care that minimizes risk requires coordination among providers, including what specific concerns prompt a referral and clarity about who will follow a problem to a definitive diagnosis.
A 46-year-old female was seen by her PCP for a complaint of constipation and bleeding with bowel movements over the past five weeks. The patient had a history of hemorrhoids, and the PCP ordered a referral to GI for a sigmoidoscopy. Due to scheduling constraints, the sigmoidoscopy could not be performed for two months. The sigmoidoscopy revealed formed stool and a small polyp in the rectum. Biopsy results showed colonic mucosa and mild fibromuscular hyperplasia, with no evidence of adenoma.
Over the next 11 months, the patient was seen at the PCP’s practice for episodic care, before an urgent visit with her PCP for weight gain and constipation. She was told to increase fiber in her diet and to consider a colonoscopy at some point. Four months later she returned again with recurrent constipation, and was prescribed lactulose. The following month she was referred for a colonoscopy, but before that appointment, she presented to the ED with acute lower left quadrant abdominal pain and emesis after taking the phosphosoda colon prep.
As part of the ED workup, a CT scan showed a complex multiloculated cystic mass in her pelvis, associated with peritoneal carcinomatosis and ascities. The results were worrisome for ovarian cancer and possible partial colonic obstruction, secondary to peritoneal disease adjacent to the sigmoid colon. Three days later, the patient underwent extensive surgery; pathology revealed metastatic adenocarcinoma of the sigmoid colon. She died three months later.
The family sued the PCP, alleging wrongful death as a result of failure to timely diagnosis and treat colon cancer.
This case settled for more than $1 million.
- The patient had trouble making an appointment to schedule the initial sigmoidoscopy.
Specialty practices need scheduling systems to take into account when patients have an active complaint. This ensures timely testing results for formulation of a diagnosis and treatment plan. Systems may include an “open” scheduling model where appointment time is available for urgent issues. Primary care offices can further ensure appropriate and timely testing, by indicating in referral notes to specialists that the request is for diagnostic—not screening—imaging and what the focus of concern is.
- A narrow diagnostic focus may have contributed to the delay in ordering appropriate colon visualization.
Adequate assessment of clinical presentations and a thorough history and physical enable the clinician to make a differential diagnosis. Education about recommendations for colon visualization per recognized guidelines and algorithms, gives the provider extra tools to reach a diagnosis, order the appropriate testing, and develop a treatment plan.
- The patient’s concerns continued over a year and a half with multiple providers without a definitive diagnosis.
Keeping track of a clinical complaint until it is definitively resolved is particularly challenging in outpatient primary care. Patient visits tend to be episodic, and providers need their office systems to support good follow-up with automatic reminders, prominent problem lists at the front of the patient’s record, etc. Unresolved patient symptoms over an extended period of time likely necessitate a referral to a specialist for additional testing. Coordination of care between the specialist and PCP ensures that the unresolved problems are aggressively addressed and that each provider is clear about who is responsible for follow-up.