Texas Medical Liability Trust

Failure/delay in diagnosis: cancer

Clinical presentation
A 47-year-old man presented to a large multi-specialty clinic complaining of burning chest pain. Ten years earlier, the patient had undergone a thoracotomy for the removal of a 10 x 5 cm fibrous dysplasia from the fifth right rib.

Physician action
The patient was seen by his primary care physician, who ordered x-rays and a cardiology consult. The x-rays showed a 3.93 x 4.54 cm right hilar mass. A CT was ordered, and the scan was interpreted by the radiologist as a cystic thymoma. The report stated “there is a mass measuring 3.93 x 4.54 cm in the anterior mediastinum. A cystic thymoma seems a very good possibility - a thymoma would be a first consideration - benign or malignant cannot be determined radiographically. Ten percent of thymomas can be cystic rather than solid.” The cardiologist referred the patient back to the primary care physician because the chest pain was not cardiac.

The primary care physician felt the appropriate course of action was to monitor the mass by x-ray for evidence of growth. A chest x-ray taken 6 months later was interpreted to show no change in the mass.

The patient returned less than a month after the second x-ray, complaining of chest pain. He was seen by another primary care provider in the practice. The second physician felt the chest pain was due to overexertion, as reported by the patient. Six months later, the patient returned for symptoms of poison ivy, and was seen by a third physician in the practice. Three months later, the patient’s primary physician saw the patient for symptoms of the flu. The next month, the patient returned with complaints of mid-sternal chest tightness. The primary physician ordered an upper GI, which showed a small hiatal hernia. This was the patient’s last visit with the primary physician. It was later discovered that the primary physician made a late entry into the chart for this visit after receiving a notice of claim letter. “See cardiologist if continues” was added in an attempt to show that he referred the patient to the cardiologist if his symptoms persisted.

Over the next year, the patient returned and was treated by the second physician for symptoms including allergy, persistent cough, chest pain and puffy eyelids. Approximately 27 months after the initial x-ray revealed the mass in the patient’s chest, he presented with significant swelling in his neck. A CT scan was ordered and revealed substantial growth in the chest mass to 11 x 8 cm. There was significant displacement of the superior vena cava. The patient was referred to a cardiologist who performed a CT guided biopsy that revealed the patient had Non-Hodgkin's lymphoma, large cell type, B-cell origin. Surgical resection was not an option.

The patient was sent for chemotherapy, radiation and eventually underwent a stem cell transfer. The patient’s cancer had metastasized to his pancreas, liver, kidney and left femur.

Allegations
• failure to diagnose/treat Non-Hodgkin’s lymphoma

• failure to perform appropriate tests, including a biopsy that would have led to earlier diagnosis

• failure to ensure continuity of care

• vicarious liability for the acts of the defendant physicians

Legal principle
Overall, expert consultants were critical of the primary physician’s actions in this case. Specifically, it was felt that monitoring a tumor with chest x-rays did not meet the standard of care. Most experts felt the mass should have been biopsied or the patient referred to another specialist to determine how the mass should be followed.

Consultants were divided in their evaluation of the treatment rendered by the second physician. This physician treated the patient five times and did not note the CT scan report. However, it was noted that on all but one of those visits, the patient made no complaints and was experiencing no signs or symptoms related to his chest mass. Additionally, the second physician was not the patient’s primary care physician, and therefore did not have responsibility for his overall medical care.

Consultants were concerned however, about the continuity of care received by the patient and the quality of record documentation by the various physicians. During the time he was treating the patient, the second physician did not communicate with the primary physician at any time about the patient’s care. One expert stated that the primary care physician’s decision to follow the mass with x-rays was appropriate, but that the care at the clinic fell apart when x-rays were not continued to document the mass.

Disposition
This case was settled for seven figures on behalf of all defendants.

Risk management considerations
Because the primary care physician in today’s health care system is viewed as the director and coordinator of that care, a breakdown in appropriate and timely continuity of care can result in a failure to diagnose and treat. Hindsight, admittedly, continues to be perfect but the standard of care was not met in this case. The chest CT report stated the mass could not be identified as benign or malignant radiographically. The next treatment choice indicated, according to consultants, should be biopsy.

Alteration of a medical record after notice of a claim breaches proper medical record documentation and will be discovered when a defendant is under oath. A clearly identified addendum or late entry may be written in a timely manner. Any late entry/addendum made in a medical record should be identified as such and include the reason for the note, reference the date and time of the actual encounter and clearly state the date and time of the added notes.

Never alter a medical record. Once discovered, changing a record seriously damages the credibility of any physician as there is no reasonable explanation for this choice of action.