• Systems are vital to facilitate reminders for routine screenings.

• A presumptive diagnosis may blur the response to subsequent complaints/symptoms.

• Patients can play a role in reducing risk if they are engaged in their care and understand the importance of recommended tests.

The patient’s family sued the PCP for failure to properly screen for colon cancer, or follow up on symptoms, causing a delay in the diagnosis of colon cancer, and resulting in the patient’s death.

Clinical Perspective

1. According to clinical guidelines at the time, the patient did not receive colorectal cancer screening appropriate to his risk, based on age.
   Use of current national colorectal cancer screening and clinical practice guidelines, such as the CRICO/RMF Colorectal Cancer Screening Algorithm, can assist clinicians in 1) assessing a patient’s level of risk for developing the disease, 2) offer an appropriate screening modality according to that risk level and the patient’s preference, and 3) identify the advantages and disadvantages of each selected screening modality.
   
   For those individuals at “Average Risk,” the following screening modalities should be considered: either colonoscopy every 10 years; flexible sigmoidoscopy every five years, with or without fecal occult blood testing (FOBT); or annual FOBT (home test with three separate stools). For those at higher risk see the CRICO/RMF Colorectal Cancer Screening Algorithm.

2. The patient’s symptoms were not adequately addressed by the PCP.
   Having a cognitive fixation or narrow diagnostic focus can contribute to failing to timely identify a serious condition. Knowing a patient very well can lull a clinician into a lack of objectivity. Clinicians need to be encouraged to broaden their differential diagnoses, seek additional information, or consider a consult when dealing with a patient with continued symptoms or significant unexplained weight loss.

Patient Perspective

1. The patient was not aware of the importance of the recommendations for screening colonoscopy.
   A long-term relationship between patient and physician is usually a positive attribute, and patients often take the recommendations of their doctor very seriously. Physicians should strive to increase awareness and encourage regular colorectal cancer screening at age-appropriate intervals. Document the counseling, education, and physician recommendations, along with the patient’s response, including deferral or refusal.
   
   

Risk Management Perspective

1. The PCP did not readdress a screening colonoscopy following the routine physical, as he had planned.
   Health care providers are extremely busy people with an incredible amount of things to remember when seeing and evaluating their patients. Although a physician may contemplate ordering a screening test, a reliable system must be in place to ensure that the issue is addressed at the patient’s next visit. To ensure important issues don’t get overlooked, providers should routinely review their documentation of previous visits (e.g., previous complaints, tests ordered, results of those tests, previous plans of care, etc.) before evaluating their patients. Providers should also develop systems, whether electronic (e.g., imbedding guidelines/algorithms into their EMR) or paper (e.g., paper tickler file) that remind them when routine screenings should be scheduled.
   
   

Legal Defense Perspective

1. Experts for the defense team were unable to support the PCP, based on the standard of care for cancer screening.
   Juries tend to support physician defendants when presented with evidence that they did what any other qualified physician in the same specialty would do. When guidelines exist for a specific clinical situation, documentation of the defendant’s adherence or rationale for following, or not following the guideline for a particular patient is crucial. Otherwise, the likelihood of a successful defense at trial is reduced, and financial settlement is in everyone’s best interest.