Presentation
A 54-year-old woman returned to her primary care physician, Family Physician A. The patient reported pain in her left arm, chest, and back that had continued for a week. The patient’s history included hypertension, fibroid tumors, and a hysterectomy. The patient was also a smoker.
Physician action
During the patient’s visit in January 2007, the Family Physician A noted a moveable mass on the lower side of the left breast. The physician ordered a mammogram and recommended the patient see a cardiologist.
The results of the stress test, EKG, and echocardiogram were found to be normal, and the consulting cardiologist concluded that the patient’s complaints were non-cardiac in nature.
In February 2007, a mammogram was performed and the radiologist noted micro- calcifications occurring more centrally in the left breast with no identifiable mass at the six o’clock position. The radiologist noted that the right breast was dense with a centrally located fibroadenoma.
The radiology report stated that the microcalcifications needed further examination by either stereotactic or excisional biopsy. The radiologist instructed that the radiology report was to be faxed to both Family Physician A and the patient. Family Physician A and the patient maintained that they did not receive the reports.
Approximately 16 months later (April 2009), the patient came to a local emergency room with chest wall pain and sharp pain in the right armpit. The pain was distinct with movement. The chest x-ray showed “minimal discoid atelectasis or linear fibrosis in the left lung base,” suggestive of emphysema.
The patient was prescribed ibuprofen, cyclobenzaprine hydrochloride, and hydrocodone bitartrate and acetaminophen for pain. She was instructed to follow up with her primary care physician.
The patient made a follow-up appointment with another primary care physician, Family Physician B, two weeks later. Family Physician B ordered a mammogram of the left breast. This study was compared to the original study from February 2007. The left breast showed a possible hypoechogenic nodule or cyst at the three to four o’clock position and a small cyst at the six o’clock position. Six month clinical follow-up was highly recommended.
On June 18, the patient came to her Family Physician A for evaluation of a self-detected mass in the lower outer left breast. She also reported pain in the upper aspect of the left breast. The patient was referred to another radiologist for evaluation of the left breast.
A bilateral breast and axillary ultrasound were highly suggestive of malignancy in the left breast with several suspicious looking lymph nodes. The right breast showed a mass of calcifications. A breast core biopsy, MRI of both breasts, and left breast image-guided core biopsies were recommended.
The diagnostic radiologist completed several imaging studies on June 22 that indicated an invasive, well- differentiated mammary neoplasm with features of lobular carcinoma, showing individual cell infiltration with occasional single cells. Due to arterial bleeding, the left breast stereotactic-guided vacuum-assisted core biopsy had to be stopped, and a surgical consult was recommended for the palpable invasive lobular carcinoma.
On July 10, the patient was admitted for surgery. The surgeon performed a left modified radical mastectomy and prophylactic right total simple mastectomy for a preoperative diagnosis of left breast invasive carcinoma and right breast atypical fibroadenoma.
The pathology reports indicated extensive lymphatic vessel invasion of the medial portion of the left breast. The right breast showed proliferative fibrocystic alteration with multifocal and multi-segmented atypical lobular hyperplasia. Next, the patient had a hematology-oncology consult and began anti-hormonal therapy and chemotherapy to reduce the risk of recurrence.
In November, the patient underwent an excisional biopsy of the left chest wall mastectomy site due to pathology reporting infiltrating carcinoma of the left breast status post left modified radical mastectomy.
Allegations
A lawsuit was filed against Family Physician A, alleging:
- failure to follow up on the findings of the February 2007 mammogram;
- failure to timely recognize the possibility of malignancy in the patient; and
- failure to timely communicate the findings and recommendations to the patient.
Legal implications
Physicians who reviewed this case for the defense felt strongly that Family Physician A did not provide timely follow up on the results of a mammogram. There was no office policy or procedure in place to ensure that diagnostic tests were completed in a timely manner and results obtained for review.
The reviewers also criticized Family Physician A for not scheduling a follow-up appointment to discuss the test results. Some reviewers were marginally supportive of Family Physician A since the patient did not make any attempts to follow up regarding the diagnostic studies. The majority of the reviewers agreed that the patient would have had a more favorable outcome if the diagnosis had not been delayed for 16 months. Additionally, the reviewers suggested that the radiologist did not make sufficient efforts to contact the patient or the primary care physician with the abnormal test results.
Disposition
This case was settled on behalf of Family Physician A.
Risk management considerations
According to a breast cancer study by the Physician Insurers Association of America (PIAA), the most common allegation in breast cancer claims is error in diagnosis including delay in diagnosis, failure to diagnose, and misdiagnosis. Diagnostic errors resulted in payment 44% of the time. (1)
When diagnostic tests are being ordered for suspicion of cancer, tracking and follow-up appointments are essential. There are numerous tools that physicians can establish to minimize the possibility of a delayed diagnosis. Physicians can develop a policy and procedure for tracking diagnostic testing and receipt of results. The policy and procedure can be enhanced with dedicated personnel who assist to schedule diagnostic testing, monitor tracking logs, make appointment reminder calls, and follow up on patients who do not keep their scheduled appointments.
Also, physicians can develop a procedure that at each appointment patients will schedule their next follow-up appointment. Having patients schedule while in the office can also help reduce the number of inbound phones calls that staff must manage. It is recommended that physicians document in the patient record when patients are instructed to return for a follow-up appointment.
Documentation of discussions with their patients is valuable in the event of a claim or complaint. Discussion of the risks, benefits, and alternatives of treatment options should be documented in the patient chart. Documentation of the patient’s informed consent and understanding of the treatment plan and diagnostic testing will demonstrate the physician’s efforts to provide education to the patient.
Source
1. PIAA. Breast Cancer Study. MPL Cancer Claims Miniseries: Volume 1. November 2013. Rockville, MD.
These closed claim studies are based on an actual malpractice claims from TMLT. These cases illustrates how action or inaction on the part of physicians led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician’s defensibility. These studies have been modified to protect the privacy of the physicians and patients.
