KAILUA KONA, HAWAII — The most commonly missed diagnoses that result in lawsuits against primary care physicians typically involve younger patients, insurance data suggest.
Half of the suits against family physicians for negligence or adverse outcome claim diagnostic error or failure to supervise or monitor cases. “These are sins not of commission but of omission,” Dr. Robert B. Taylor said at a meeting on medical negligence and risk management.
A study of 49,345 claims against family physicians found that no single medical problem accounted for more than 5% of claims, he noted. Myocardial infarction led the list with 5% of claims, followed by breast cancer and lung cancer, tied for second place with 3% of claims each (Qual. Saf. Health Care 2004;13:121–6).
A profile of negligence claims involving acute myocardial infarction emerged from a separate analysis of 349 claims by the Midwest Medical Insurance Company Risk Management Committee, said Dr. Taylor, professor of family medicine at Oregon Health and Science University, Portland.
Most of these cases involved diagnostic errors. The average patient age was 52 years—a young age for heart attacks—and 70% of these patients had no prior history of coronary artery disease. Physicians encountered a majority of these patients in their offices. Although at least 93% of the patients had typical symptoms such as chest pain, shortness of breath, or pain down the arm, physicians did not consider a diagnosis of acute myocardial infarction in half the cases, performed no diagnostic studies in 28%, and never made the diagnosis in 79%, he said at the meeting, sponsored by Boston University.
Most of these claims were filed against family physicians but involved a lower average indemnity than did claims against internists or emergency physicians involving acute myocardial infarction. “There are a lot of us” family physicians, Dr. Taylor noted. “That could be a factor. I'm not sure that we get sued more often.”
Patients claimed the physicians did not respond quickly to suspicious symptoms. Those who missed the diagnosis often attributed the symptoms to something else, such as anxiety, hyperventilation, indigestion, psychosomatic problems, or gastroesophageal reflux disease.
The take-home message: “When a relatively young person walks in with typical symptoms, even if they've never had coronary artery disease, don't take shortcuts in the evaluation” for acute myocardial infarction, Dr. Taylor said.
A separate analysis of data on 3,150 claims involving breast cancer by the Physician Insurers Association of America found two major causes of missed diagnoses. The patient's physical findings failed to impress the examiner, or the examiner failed to follow up with the patient after the initial examination of a breast lump.
Patients whose breast cancer was missed by physicians tended to be those with a chief complaint of a painless mass that they discovered themselves, and who had negative or equivocal mammograms. Sixty percent were younger than age 50 years.
“This profile I hammer into my residents,” Dr. Taylor said.
Remember that 1 in 10 women will get breast cancer in their lifetime, and don't put too much trust in mammography alone, he advised. Consider getting an ultrasound as well as a mammogram in questionable cases.
To reduce the risk of adverse events and malpractice claims, maintain your clinical competence and stay up to date with clinical guidelines, Dr. Taylor suggested. Practice relationship-based medicine.
Keep up communication with patients and their families, be alert to high-risk problems, and be thorough with lab results, return visits, and other follow-up procedures. Practice within your abilities and get consults or refer when needed, Dr. Taylor said.
'When a relatively young person walks in with typical symptoms … don't take shortcuts in the evaluation.' DR. TAYLOR