Case Study: Assumptions Among Providers Delay Dx

A female patient wasn’t screened for colon cancer, despite routine involvement with three physicians.

Commentators

• Richard Parker, MD; Beth Israel Deaconess Medical Center; Boston, MA

Transcript

The following case abstract is based on closed claims in the Harvard system. Some details have been changed to protect identities.

A 64-year-old woman, with no family history of colon cancer, called her PCP with complaints of bright red rectal bleeding and discomfort.  She was immediately referred to a gastroenterologist and diagnosed with colon cancer. At issue is whether, during the nine years prior to presentation, she should have been offered colorectal screening and evaluated for vague but persistent abdominal complaints.

From age 44 to 59, the patient was under the care of the same gynecologist until he retired. During that time, she complained twice of a “pulling sensation” in her right lower quadrant. A barium enema, after the first complaint, was normal. After the second complaint, a rectal vaginal exam was also documented as normal .

A year later, when the patient started with her new gynecologist at age 60, she also obtained a primary care provider for the first time, and began a series of annual exams with each doctor. The PCP asked the patient whether she had had colorectal screening. The patient, thinking the barium enema and digital exams with her prior physician qualified as screening, indicated that she had. No previous records were obtained to identify the type of test, nor was sigmoidoscopy offered. Annual exams with the new PCP included rectal examination with negative stool guaiac.

Visits to the gynecologist also included rectal examinations. Two years after the patient started with her new gynecologist, she complained of “a pulling sensation for the past two years.” The gynecologist’s record for this patient contained no documentation of either communication with the PCP or a referral to GI for the issue The new gynecologist assumed that the patient would follow up with her PCP. She was viewed as an intelligent, organized, and responsible patient, as she was vigilant about annual appointments, pap smears, and annual breast cancer screening.

Two years after that GYN visit, the patient contacted her PCP with a complaint of rectal bleeding and discomfort. The gynecologist soon received a call that the patient had undergone a colonoscopy that found several polyps, including one that was very large and potentially cancerous.

Within eight months, the patient was diagnosed with colorectal cancer, with metastasis of the lung, and she died two years later.

The patient’s estate sued both the gynecologist and the primary care physician, alleging negligent delay in diagnosis of colon cancer and failure to appropriately screen for cancer. The case was settled in the high range.

To discuss the risk management and patient safety aspects of this case, we are joined by Dr. Richard Parker. Dr. Parker is an internist and is Medical Director for Beth Israel Deaconess Physician Organization in Boston.

Dr. Parker, thank you for joining us.

My pleasure.

Let’s get right into the cross specialty relationships with a single patient, which seemed to complicate an otherwise straightforward screening or diagnostic process, and led unfortunately to a large settlement in a malpractice case.

Sure.  This case illustrates the pitfalls and problems of two doctors assuming that the other one may be doing an important screening test.  So, for example in this case a woman over the age of 50 who at least needed colon cancer screening did not get it. And part of the problem was the internist may have assumed that the gynecologist was doing it and the gynecologist may have assumed that the internist was doing it and these assumptions obviously can lead to very negative consequences for the patient and the doctors. This kind of situation, I think, can be addressed by not assuming and being actually factual and having the doctors communicate explicitly about who is doing this screening. Usually for colon cancer screening the internist would do it, although there are circumstances in which a gynecologist could send the patient home with a home stool guaiac test or even could send the patient for a screening. But the take home point is the internist and the gynecologist must agree on who is doing what.

It is interesting, the word ‘assumptions,’ because there were assumptions about the patient herself too, that she was a highly educated and very resourceful and responsible person about her own screening and her own healthcare, and so there were some assumptions made there that she would pursue follow up on a symptom or just know that she needed to be screened. So even with an intelligent, educated patient that assumption can be risky?

I think sometimes educated, intelligent patients present the higher risks for doctors because doctors assume that if, for example, they’ve told a patient like this one time ‘please call and schedule a colonoscopy,’ it will be done and it certainly may not be done. And doctors have the same responsibility toward any patient in terms of follow up and follow through to make sure that a screening procedure that was advised was actually accomplished. 

Each of the physicians had their own sense of responsibility for aspects of the patient’s care, their own processes for insuring that the right thing gets done at the right time with the right kind of follow up. Where do we start to untangle the nitty gritty of preventing this outcome, if possible the clinical outcome for this patient, but at least prevent any unnecessary delays?

I think in this case, as in so many cases, we need to distinguish between surveillance screening and testing for signs and symptoms.  The screening for an asymptomatic patient over the age of 50 in my opinion falls fully in the bailiwick of the internist, of the PCP. Once this patient started to have symptoms of any sort referable to the GI tract, and she came to either the internist or the gynecologist, both of those doctors were on the hook to make sure that she got the appropriate evaluation, either by way of referral to a gastroenterologist or simply by sending her directly for a colonoscopy or other testing that would get to the bottom of the symptoms that she was complaining of.. Screening is something that is very easy for doctors to forget about in a busy visit. And my suggestion is that, whenever possible, doctor’s offices have these screening procedures routinized or systematized in such a way that they don’t have to rely on their own memory. 

If a doctor’s office has an electronic medical record it should be pretty simple to prompt them that screening is due or overdue.  If they are using paper records there should be a flow sheet that has screening down one side and dates across the other side and the doctor or the doctor’s assistant can say, ‘gee, this patient is overdue let’s get it done.’

What is an example of how that switches over from surveillance screening to diagnostic testing?

Specifically, a patient who comes in complaining of change in bowel habits, constipation, diarrhea, change in the caliber of the stools, any complaint of bleeding or unanticipated weight loss would be triggers for a diagnostic strategy rather than a surveillance strategy. The other difference between surveillance strategies and strategies for diagnosing possibly underlying colon cancer is the follow up has to be quicker and, I don’t want to say more certain—because the follow up is important in both cases—but when patients are symptomatic the follow up needs to be very timely.

Thank you. Dr. Richard Parker is Medical Director at Beth Israel Deaconess Physician Organization. For Resource, I’m Tom Augello.