Beware of the Agreeable, Noncompliant Patient

This month, we feature an article from the archives written by CAP’s former General Counsel Gordon Ownby.

Knowing a Patient Well Can Interfere with Good Judgment

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Dr FP, a family practitioner, had been treating his amicable, 45-year-old patient for some 20 years. The patient, a SCUBA dive travel operator, complained during one visit of pains along her backside for the past six months. On examination, Dr. FP found chest and abdominal pain, plus shortness of breath. He ordered a complete blood workup, other lab evaluation, and an abdominal CT scan.

The CT scan showed a solid-appearing mass in the left midlateral kidney. The radiologist telephoned Dr. FP twice about his suspicion of cancer and recommended a bone scan and an abdominal ultrasound of the left kidney. Dr. FP advised the patient of the findings and of his plan to refer her to a urologist after the two additional studies were done.

Doctor Reminds Patient to Schedule Test

Dr. FP’s clinic called the patient to let her know that it had scheduled the ultrasound and bone scan tests, both to be done on the same day. The patient went for the bone scan but did not show up for the ultrasound. On the day after the scan, Dr. FP’s clinic called the patient to let her know that the scan was negative.

Six weeks later, the patient returned to Dr. FP complaining of body aches, sinus pain, and a scratchy throat. Dr. FP treated the patient for an upper respiratory infection and took a throat culture. During the visit, Dr FP reminded the patient to schedule the abdominal ultrasound and gave the patient the telephone number to schedule the appointment.

Dr. FP called his patient back a week later, leaving a message on her telephone machine stating that she had a bacterial infection and that she should finish the medications prescribed to her. He also stated (and charted) his advice to “Don’t forget to schedule the ultrasound.”

Patient Was a “No Show”

The patient next returned to the clinic some four months later, complaining of menstrual irregularity. A colleague of Dr. FP saw her that day and again four days later, when the physician diagnosed early menopause. She was a “no show” for an appointment three months later.

Over the course of the next two and a half years, the chart shows the patient visiting the clinic several times, with the staff again making appointments for her abdominal ultrasound, which the patient did not keep. The patient repeatedly told the office and doctors that she was very busy and had to make numerous trips abroad.

When the patient finally had an abdominal ultrasound performed (37 months after first ordered), the results showed a 4.8 × 3.8 cm, hypervascular mass in the left kidney suggestive of renal cell carcinoma. Upon receiving the ultrasound report, Dr FP called the patient to discuss the test results and told her she should see a urologist that same day. He gave her the names of two urologists who could evaluate the mass.

Another five months passed without a visit to a urologist. An abdominal MRI, however, showed a solid left interpolar renal mass with hypernephroma. The radiologist noted no renal vein invasion, but two right lobe lesions. The differential diagnosis was benign hemangioma versus metastasis.

At a visit to the clinic four days later, the patient discussed her examinations with Dr. FP’s colleague. The patient told the physician that she would proceed with a urologist and oncologist at a university hospital. A subsequent lab report from the hospital showed left kidney chromophobe renal cell carcinoma stage III, with one lymph node involved.

Patient Sues for Delayed Diagnosis

The patient underwent a nephrectomy and sued Dr. FP and the clinic for delayed diagnosis of her cancer. Though acknowledging her client’s own inaction, the patient’s attorney criticized Dr. FP’s lack of “written or oral policies, procedures or a custom and practice for documenting conversations with patients about life-threatening illnesses.” The attorney claimed that Dr. FP should have referred the patient to a urologist after the initial test results.

The parties reached an informal resolution of the case.

In this case, office protocol (since changed) appeared to distinguish between patients who refuse to undergo a test versus those who simply delay action. It may not be the confrontational patient who is a danger to her own health, but the charming one.