When pain persists, so should investigation
TWO WEEKS OF ABDOMINAL PAIN brought a 63-year- old man to a group medical practice where an internist attributed the pain to gastritis and prescribed an over-the-counter medication.
The internist examined the man several times over the next 4 years, during which time the man complained periodically of nausea and abdominal pain and the doctor prescribed antacids. A different physician who examined the patient during this period recommended referral to a gastroenterologist. Although the internist was told of the recommendation, he didn’t make the referral.
Four years after the patient first reported abdominal pain to the internist, he was diagnosed with stage IV colon cancer. He died the following year at 68 years of age.
PLAINTIFF'S CLAIM The colon cancer should have been diagnosed when the patient initially complained of pain. His symptoms and age called for an immediate colonoscopy (which would have detected the cancer) or referral to a gastroenterologist.
THE DEFENSE The internist maintained that the pa- tient had been advised several times to undergo a colonoscopy and had refused to do so, although records didn’t support that claim. Earlier treatment wouldn’t have changed the outcome.
VERDICT $950,000 New York settlement.
COMMENT I do a fair amount of malpractice case reviews and find that most cases arise from diagnostic delays and missed diagnoses. This physician’s initial approach may have been sensible, but persistence of symptoms is always a reason to escalate the diagnostic approach, and early referral is necessary in the absence of a definitive diagnosis.
Failure to reconsider the initial evaluation
A 29-YEAR-OLD MAN complained of chronic constipation (3 years) and recent rectal bleeding at his first visit to an internist. The doctor performed a rectal examination and ordered a colonoscopy, which was negative and didn’t reveal the cause of the bleeding.
The following year, the patient returned to the internist, reporting new rectal bleeding. After a digital rectal examination, the doctor diagnosed internal hemorrhoids. She continued to treat the patient for the next 3 years. During that time, the patient reported rectal bleeding on 2 occasions; the physician diagnosed external hemorrhoids.
Almost 5 years after his first visit to the internist, the patient requested another colonoscopy, which revealed rectal cancer. After receiving radiation and chemotherapy, the patient underwent abdominoperineal resection with removal of the sphincter muscle, resulting in a permanent colostomy.
PLAINTIFF'S CLAIM The internist couldn’t have diagnosed internal hemorrhoids by digital exam alone unless the hemorrhoids were prolapsing. She was negligent in failing to perform an anoscopy or refer the patient to a gastroenterologist to confirm the cause of the rectal bleeding. Proper management would have enabled diagnosis of the cancer at a stage when radical surgery could have been avoided and the sphincter muscle preserved, eliminating the need for a permanent colostomy.
THE DEFENSE The internist claimed she had diagnosed prolapsing internal hemorrhoids, although the chart noted only internal hemorrhoids. Reliance on the initial negative colonoscopy was proper; earlier diagnosis wouldn’t have changed the patient’s treatment and outcome.
VERDICT $934,779 Illinois bench verdict.
COMMENT This is a difficult case. Colon and rectal cancer are very rare in 29-year-olds, and the initial evaluation was appropriate. At what point should the physician have re-evaluated with colonoscopy or anoscopy and biopsy? I don’t think any retrospectoscope will provide a definitive answer. If this case offers a take-away lesson, it is to reevaluate when potentially serious symptoms persist.