Description

A 66-year-old male with lower urinary tract symptoms was diagnosed with benign prostatic hypertrophy one year before a diagnosis of advanced prostate cancer.

Key Lessons

Clinical Sequence

Allegation

Disposition

The case was settled in the mid-range.

Analysis

Clinical Perspective

1. Faced with worrisome PSA values for this patient, the PCP relied on a referral to urology to diagnose the patient’s symptoms, yet did not share the PSA values with the patient or the specialist, and did not react to the specialist’s report when it did not address the worrisome PSA values.
   Patients generally are not reliable reporters of critical clinical information in the referral process. A formal referral should include the concerns and relevant data related to those concerns. Otherwise, a specialist will rely on patient complaints and new evaluations to guide his or her differential diagnosis. A PSA test is not indicated for complaints of nocturia and polyuria. Absent any information about prior PSA testing, a DRE and GU examination would be appropriate to address prostate cancer in a specialist’s differential for those symptoms. A referring physician’s practice should have a reliable system for ensuring that a specialists report comes back and is reviewed by the referring provider.

 

Patient Perspective

1. The patient argued that the urologist should have ordered a PSA level when he presented with urinary frequency and nocturia.
   Symptoms such as nocturia and urinary frequency do not indicate increased risk of prostate cancer. Providers treating these symptoms should discuss the limits and risks of PSA testing so patients understand recommendations and conclusions. PSA tests have not been shown to reliably result in earlier diagnosis of prostate cancer; earlier diagnosis of prostate cancer has not been universally shown to significantly reduce mortality and morbidity, as major studies disagree on this point so far.
2. The patient felt that he should have been diagnosed earlier, and if he had, he would have been an operative candidate; yet one of two DREs, a bone scan, and a pelvic CT failed to confirm the cancer after it had been identified by other means.
   Findings between DREs performed by two physicians can be significantly different, reflecting the subjective nature of the exam. Even objective tests, such as CT and bone scan can also fail to detect abnormalities. A patient receiving bad news and disappointing options may find comfort in knowing that the care leading up to the diagnosis was proper, but the reassurance must not be self-serving.

 

Risk Management Perspective

1. Communication between the PCP and the urologist should have occurred before the urology evaluation to specify the reason for referral, and after the evaluation to summarize findings and plan of care.
   PCPs can improve the potential for a timely and appropriate evaluation by completing a written referral that outlines diagnostic findings and the reason the patient requires a specialty evaluation. A specialist should provide the PCP with feedback of his findings, including a copy of his initial evaluation, follow up recommendations and plan of care.
2. The patient should have been notified of his abnormal test result and advised of the need to follow up and discuss further with his physician.
   Physicians need a reliable system to notify patients in writing of all abnormal test results. It is necessary to document discussion with the patient about the need to follow up with their physician for further evaluation.
3. Use of a medical interpreter may have led to a more thorough history and physical. It would also have increased the chances that the patient understood his test results and the need for further evaluation.
   Inadequate communication can have tragic consequences. A medical interpreter should be used for communication when a language barrier is present. Family members are not a first choice for interpretation, due to the potential for cultural bias and personal agendas.

 

Legal Defense Perspective

1. The defense successfully argued at tribunal that there are no practice requirements for obtaining a PSA level for prostate screening, and that the patient’s symptoms improved with treatment. Even when a legal defense is successful, the difficulty of enduring a malpractice claim may be avoidable. Several elements of a medical case can lead to allegations of negligent delay in diagnosis: the failure of a provider to notify the patient of abnormal results, lack of communication among providers caring for the same patient, and failure of a specialist to order a diagnostic test. Efforts to create reliable office systems to facilitate communication and follow-through that prevents these failures can help minimize risk of a claim being brought.