Sued for misdiagnosis? It could happen to you
Plaintiffs’ attorneys and patient safety advocates alike are increasingly focusing their attention on diagnostic errors. Here are the key pitfalls and ways to avoid them.
Is it cancer? Failure to test or follow up
Cancer may not be the most frequently misdiagnosed condition, but because of the dire consequences often associated with a delay in detection, cancer is No. 1 in frequency of diagnostic error lawsuits13—with breast cancer typically at or near the top of the list. Evidence suggests that clinician preconception plays a role.
Most women who develop breast cancer are over the age of 50, but plaintiffs in breast cancer suits tend to be younger.14,15 This may be partly because of overreliance on age as a predictive factor, causing some physicians to offer a younger woman what may be unwarranted reassurance that a breast lump is due to fibrocystic tissue rather than malignancy (CASE 1).
Ordering a test is not enough. Even when physicians order the correct test, follow-up may fall short. In the closed claims study, physicians incorrectly interpreted test results in 37% of the cases.12 Other evidence suggests that about a third of women with abnormal mammograms do not receive follow-up care that’s consistent with established guidelines.16
What’s more, physicians sometimes overlook the fact that diagnostic tests are rarely 100% accurate. Mammography misses approximately 20% of breast cancer cases,17 for example, and a woman with a palpable lump should be closely watched, not dismissed on the basis of a negative mammogram result.1,15
What happens to test results? In other cases, the problem is not that a test result doesn’t match the clinical findings, but that the result is not reviewed by the physician or conveyed to the patient in a timely manner. Indeed, the title of a published report of a survey of internists starts with the quote, “I wish I had seen this test result earlier!” 18 Of the 262 internists surveyed, only 41% expressed satisfaction with their method of handling test results.
What would satisfy these physicians? Respondents said what they wanted in a test result management system were tools that would help them generate letters to patients detailing the results, prioritize their workflow, and track orders for tests to completion.
A 32-year-old woman sought care for “sore breasts” 4 months postpartum. Her primary care physician found “bilateral lumpy and tender breasts,” diagnosed fibrocystic breast disease, and prescribed a nonsteroidal anti-inflammatory drug. There was no follow-up plan documented.
She returned in 4 months, stating her symptoms were better but she still had soreness in her left breast. The physician did not examine her, but changed her medication to a different anti-inflammatory. Follow-up was to “return to clinic PRN.”
On her next visit she complained of a lump in the left breast. The physician found a “spongy irregular 2 cm lump” in the upper outer quadrant of the breast, diagnosed a fibrocystic lesion, and reassured the patient. Follow-up again was to return PRN.
Several months later, the patient saw another physician, for back pain and a painful and enlarging breast lump. The physician suspected fibrocystic disease but was unable to obtain fluid by fine needle aspiration. The patient was referred to a surgeon, who obtained a nondiagnostic needle biopsy and an excisional biopsy, which revealed breast cancer. The patient’s back pain turned out to be from metastatic breast cancer. She sued for failure to diagnose breast cancer. The case was settled for an undisclosed large sum.
Commentary: Failure to diagnose breast cancer is a leading cause of malpractice lawsuits, many of them in younger women. Plaintiff recoveries correlate with the length of the delay in diagnosis.
In this case, experts identified a series of missteps in the care of this patient which, when combined with a young, very sick, and sympathetic plaintiff, led to a large recovery. Although it may have been reasonable to diagnose fibrocystic disease on the first visit, experts cited the failure to take a family history (the patient’s aunt and maternal grandmother had had breast cancer) and the failure to document a follow-up plan as damaging to the doctor’s case. They also faulted the physician for failing to examine the breast on the second visit and failing to do fine needle aspiration or refer on the third visit, and for the nonspecific follow-up plans.
Diagnostic lesson: Although breast cancer is less common in women younger than 40, it does occur, and the same diligence in examination, charting, and follow up is required regardless of the patient’s age.
By the way, doc… Harried physician, hurried response
What physician isn’t familiar with the patient who comes in for care of 1, or several, chronic conditions, but mentions another problem as he or she is getting ready to walk out the door (CASE 2)? If that problem appears to be a transient and treatable condition, the temptation is to make a hasty diagnosis and write a prescription, without the usual degree of history taking, patient examination, contemplation, or documentation. Doing so, however, poses considerable risk, to both patient and physician.
