When a patient presents to an emergency room with a large nail sticking out the side of the head with the chief complaint of “My head hurts,” it is not much of a challenge for the healthcare provider to diagnose the cause of the patient in question’s pain. But what healthcare providers know and the general public does not always appreciate is that “diagnosis” is as much art as it is science. Hence, the reason why a physician will often document the “differential diagnosis,” or the list of possible diagnoses for a patient’s presenting symptoms. Notwithstanding the assumptions of a large segment of the population (including many personal injury attorneys), a failure to properly diagnose a patient is not necessarily medical malpractice. One of the key variables can be simply summarized as “age matters.”
Let’s look at two examples:
A 67-year-old female presents to a gynecologist with complaints of continued bladder pain after having been diagnosed with, and treated for, a urinary tract infection a month previously by her primary care physician. An ultrasound revealed an enlarged uterus filled with fluid. The uterus was drained, a biopsy performed and specimen sent to pathology. The patient was diagnosed with a pyometra, which is an “accumulation of pus in the uterine cavity resulting from interference with its natural drainage. It is an uncommon condition that occurs mainly in post-menopausal women. It is considered a clinically important disease as the majority of pyometra is associated with malignant lesions of the genital tract…”**
A gynecological oncologist was consulted and he recommended a repeat biopsy in three months. The repeat biopsy three months later was inconclusive, but there was bleeding or hematometra noted in the uterus. Due to suspicion of cancer, the patient was referred to the oncologist for a Dilation and Curettage (D&C). In the recovery room following the D&C, the patient went into septic shock and was admitted to the ICU. She continued to deteriorate and died the following day.
A medical malpractice complaint alleged that both the treating gynecologist and the oncologist should have considered an infection and started the patient on antibiotics. It was alleged that the gynecologist should have ordered a culture of the specimen of the drainage material obtained during the initial treatment and that the oncologist should have started the patient on prophylactic antibiotics a week before the D&C.
The Medical Review Panel unanimously ruled in favor of both physicians and a subsequent jury trial also rendered a verdict in favor of the defendants. Contrary to testimony from “experts” retained by the plaintiffs, the two defendants and the Medical Review Panel physicians clearly outlined the appropriate standard of care to the jury. Although the patient had no signs of infection such as fever, redness, swelling or pain upon palpitation of the uterus, based on the patient’s age, complaints, symptoms and examinations/testing, a strong suspicion of cancer was reasonable. In addition, the growing concern of overuse of antibiotics has resulted in increased resistance calls for not ordering them in the absence of physical signs of infection.
The particulars of this case involve an obese 32-year-old female who presented to the ER for abdominal pain increasing over a period of about a week. The patient underwent a diagnostic laparoscopy and drainage of a periappendiceal abscess. No appendix was found so the diagnosis was perforated appendicitis with likely periappendiceal abscess. The patient had a good post-op recovery and was discharged with normal follow-up instructions. She had two follow-up visits at the surgical clinic a week and three weeks after the surgery with no complaints. Five months later, she had renewed abdominal pain that was initially suspected to be an incisional hernia at the site of the laparoscopy. During the planned surgical repair of the hernia, a mass was found and determined to be metastatic mucinous adenocarcinoma. Subsequent to this diagnosis, she developed a significant pulmonary embolus that was treated appropriately. Unfortunately, she suffered a significant cerebrovascular event, was placed on hospice and expired.
A medical malpractice complaint alleged that multiple healthcare providers failed to properly treat the patient and diagnose/treat the cancer in a timely manner.
The patient had no family history of cancer and was well under the age for suspicion of cancer. This appears to be a very sad case of development of a rare form a cancer in a young woman who initially presented with symptoms reasonably diagnosed and treated as appendicitis. Her surgery went well with no post-op complications and no medical problems during the subsequent five months.
In these present times, it is generally assumed outside of the healthcare industry that we now have the knowledge and technology to correctly diagnose and successfully treat our medical problems. It is the task of the healthcare defendant to, first of all, remain calm and patient in the face of allegations of malpractice (no easy task and easy to say for those of us who are not the defendant). The healthcare provider must then cooperate with his malpractice carrier and defense counsel to make sufficient time to explain/educate as to his/her actions i.e. the exam, the diagnosis, the treatment and prognosis.
The educational process continues in assisting defense counsel with preparing a position paper for the Medical Review Panel and, if necessary, explaining the medical process to a jury. If one can adequately articulate that a physician’s job is not to render perfect care, but to render appropriate and reasonable care, you would be surprised at how well lay juries can process complex medical information and render reasonable verdicts. Of course, juries are not perfect either, so the better job that can be done of explaining one’s thinking to the members of the Medical Review Panel, the greater chance we have for a favorable opinion with no resulting post-panel lawsuit.
This article was first published in August 2018 as an LHA Trust Funds Physicians Quarterly newsletter.
** – Pyometra: What Is Its Clinical Significance
Louis Y. Chan, MBBS, MRCOG; Tze K. Lau, MBChB, MRCOG, MD; Shell F. Wong, MBBS, MRCOG and Pong M. Yuen, MBChB, MRCOG
The Journal of Reproductive Medicine
If you have any questions related to this newsletter, please contact: