Medicolegal Issues

Failure to Order Colonoscopy Despite Patient's Family History

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A clinician misses the shared responsibility for colonoscopy screening reminders.


 

Failure to Order Colonoscopy Despite Patient’s Family History
After receiving care from the defendant primary care physician since 1997, a Massachusetts woman presented in the fall of 2003 complaining of fatigue; she was diagnosed with iron deficiency anemia in January 2004. Two months later, she underwent a diagnostic colonoscopy, which revealed a mass in the transverse colon. Following surgery to remove the obstructing cancer, the patient received palliative care and died at age 52.

Plaintiff claimed that a colonoscopy should have been ordered for the decedent at an age 10 years earlier than the age at which her youngest family member had been diagnosed with colon cancer (ie, a maternal cousin diagnosed in her early 40s, in addition to her mother, diagnosed in her early 50s, and her maternal grandmother, diagnosed at age 75).

The defendant physician claimed that the decedent’s fatigue was due to depression and that she had declined further lab tests. A handwritten entry in the medical record from 1998 indicated that a colonoscopy had been ordered and performed with negative results. However, no report from the gastroenterologist nor any billing information from that procedure was ever found in the record.

The defendant claimed that it was the responsibility of the gastroenterologist, not the named defendant, to make follow-up appointments at appropriate intervals for colonoscopy, given the patient’s family history. The defendant also claimed that the criteria for performing colonoscopies between 1997 and 2004 were still evolving and that no standards had yet been set.

Outcome
According to a published account, a $950,000 settlement was reached.

Comment
The message here is clear: Primary care providers have a responsibility to track screening requirements—even when other specialists are involved and should also have responsibility. In this case, the issue is colonoscopy screening in an individual with a strong family history for colon cancer. The plaintiff correctly argued that a colonoscopy is appropriate at an age 10 years earlier than the affected relative’s age at diagnosis, or at age 40—whichever is younger. Also, the procedure should be repeated at five-year intervals in those at increased risk. These standards were published in 1997, contrary to the defendant’s allegations, and further supported in the literature in 1999.1,2

The plaintiff began treatment with the primary care provider in 1997, with a report of colonoscopy having been done some time in 1998, yielding normal results. Certainly a primary care provider would want documented evidence of the procedure, not just a note that one had been done. Even if a colonoscopy had been performed and the note is correct that findings were normal, the time for a repeat procedure should have been some time in 2003—the same time as the patient’s report of fatigue. This is the latest that a repeat screening should have been done. Any alarm symptom, such as anemia, weight loss, rectal bleeding, changes in bowel habits, or unexplained abdominal pain would require earlier colonoscopy.

I sympathize with the provider and his/her reliance upon the specialist to make the appropriate reminder. One would hope that reminders of this type would be made by the specialist. Ultimately, a specialist who failed to make a reminder might also be liable. However, the failure of the specialist does not relieve the primary care provider of responsibility.

Further, the allegation that the patient refused a lab test would also require documentation. Without it, we have a “he said, she said” situation with no way to confirm a patient failure to follow suggested medical direction. To a jury, a statement like this appears to be an obvious effort on the defendant’s part to explain away responsibility.

In my own practice as a family nurse practitioner specializing in gastroenterology, I review active patient files at every visit to confirm screening dates and any need for repeat screening. But often I see a patient only when screening visits actually occur, sometimes 10 years apart. When I am saying goodbye to a screening patient and telling them that we will contact them with a reminder at the time of the next scheduled screening, I also tell them to make a calendar reminder themselves. We use a computer system for reminders, but we all know that computers are fallible, as are humans. Every extra level of safety is important when it comes to these matters. Ultimately, however, the primary care provider is the one who sees a patient on a regular basis and has the opportunity, and thus the responsibility, to assure that screening matters are addressed.

What is also important is that this case and its outcome occurred even before the advent of the “medical home.” With the medical home concept in place, the responsibility would likely become even greater. —JP

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