Failure to Follow Up on Breast Mass

OUTCOME
A $4.75 million settlement was reached.

COMMENT
Of the many dangers confronting diagnosticians, few are as problematic as an incidental fact that drives the workup in the wrong direction. Here, the presentation could be “breast mass and redness post–motor vehicle accident” (MVA) or simply a “breast mass.” The diagnosis may differ dramatically based on how much weight is accorded to certain facts—in this case, the patient’s nearly one-month-old car accident.

Here, we are not told the specifics of the imaging or whether the patient’s breast was tender. The primary care physician may have believed that the redness and mass were caused by the seat belt, but he was sufficiently concerned to order a mammogram, breast ultrasound, and surgical consultation.

By contrast, the surgeon accorded significant weight to the MVA in making his diagnosis. At first, a hematoma seemed plausible; however, there were clues that the mass might not be trauma-related: the initial near-month delay between trauma and presentation, the unexpected disconnect between the location of the mass and the erythema, and arguably, the negative aspiration. The primary care physician picked up on some of these clues and initially responded fairly aggressively, seeking two studies and a surgical consultation. Unfortunately, the consulting surgeon conclusively believed the mass to be a hematoma, and the referring physician, after receiving the surgeon’s comforting report, did not order the second follow-up ultrasound recommended by the radiologist.

Absent the history of the patient’s MVA, the surgeon likely would have insisted on a biopsy or fine-needle aspiration, and the outcome might have been different. We have all heard (and perhaps handed down to students) rules of diagnostic roundsmanship, including “Common things happen commonly,” and have been admonished, “Correlation is not causation.” Keep these admonitions in mind, and don’t be thrown off by what may be an incidental fact in the presentation. Don’t let the next cardiac ischemia masquerade as “pulled muscle from painting yesterday”; don’t let your next ectopic pregnancy slip by as a “bad burrito.” Give antecedent facts their due, but no more.

In sum: First, be prepared to discount what could be an incidental fact; it may save a patient’s life. Second, even after consultation, don’t jettison your initial clinical impression if you remain justifiably concerned. —DML