When a family practitioner or hospitalist gets back a radiologist’s report, it is natural to look first for the findings related to the reason for the patient’s referral. But a physician’s duty doesn’t stop there.
For several years, a middle-aged woman had been treating with her family practitioner, Dr. FP. She was an insulin-dependent diabetic, had history of heart disease, dizziness, hypertension, and knee arthroscopy, and was under further treatment by a pain management specialist for her degenerative disc disease.
In March, paramedics brought the patient to the emergency room after she developed chest pain during physical therapy. Her ER physician’s test findings were essentially negative, but for mild pulmonary edema. The ER physician ordered a CT on the brain and admitted the woman under the care of a hospitalist, Dr. H. The patient complained to Dr. H of left-sided numbness, headaches, and chest pain. Dr. H worked the patient up for cardiac issues and requested a neurology examination. She also ordered a CT angiogram to rule out aortic dissection. The radiologist reading the angiogram reported no evidence of an aneurysm, but noted a diffused prominence of the main pancreatic duct, measuring up to 5 mm. The radiologist recommended a dedicated pancreatic protocol, contrast-enhanced study versus ERCP/MRCP, for further evaluation. She transcribed her report and copied Dr. H and Dr. FP, who received the report that same day.
Also, that same day, the neurologist examined the patient, found no acute ischemia, and noted that the patient’s symptoms of severe headache and chest pain had resolved. An MRI of the brain showed no infarct and the neurologist considered the patient to have had a transient ischemic attack. The next day, Dr. H “updated Dr. FP” that the patient’s cardiac enzymes were normal and that she complained of scattered numbness in the left arm and chest. A cardiology consultation ordered by Dr. H was largely normal and Dr. H discharged the patient home on day three.
The patient followed up with Dr. FP two days post discharge, but his chart reflected no discussion of the CT angiogram report. The patient’s visits with Dr. FP into the next year were for low-back and joint pain until December of that year, when she complained of pain and tenderness of the abdomen. Dr. FP ordered an abdominal and pelvic CT, which revealed a 20x16 mm mass in the neck of the pancreas as well as lymph node enlargement. A follow-up biopsy led to cytologic diagnosis of pancreatic adenocarcinoma.
Dr. FP continued to care for the patient during her chemotherapy. Late in the year of that treatment, a liver biopsy revealed cirrhosis. After a hospice stay, the patient died at home.
Overall, the record of this patient revealed a thorough workup of the patient’s cardiac and nervous system but no investigation into the radiologist’s recommendation on her observations concerning the patient’s pancreas.
The patient’s husband and three adult children sued Dr. FP for medical negligence, alleging that the wife and mother was discharged from the hospital three years before her death with no knowledge of the pancreatic findings. In his deposition, Dr. FP offered no explanation for not discussing those findings with the patient.
Though Dr. FP prevailed at trial, his defense was based on a “causation” theory. That is, even had the patient’s pancreatic findings been worked up immediately, her cancer was of the type that intervention would not likely have saved her.
It was a trial that may have been avoided had the patient’s healthcare team addressed even those parts of the radiologist’s report that departed from what it was looking for.
Gordon Ownby is CAP’s General Counsel. Comments on Case of the Month may be directed to gownby@CAPphysicians.com. The information in this publication should not be considered legal or medical advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.