Mr. L, 59, was a physician assistant working in a very busy urology practice. He’d been there for the last two decades and was very comfortable both with his job and his specialty. The urology practice consisted of five physicians and two physician assistants, all of whom saw patients. Appointments were scheduled at 15-minute intervals, and patients had to be shuffled in and out quickly in order for the schedule to stay on track. The practice had a corporate culture of being efficient and businesslike. Mr. L prided himself on being kind and skillful, but he had no time or patience for people he perceived to be simply “cranks.” There was too much pressure to get patients in and out of the office, and too many patients with serious problems and conditions, to waste time on those who tended to be hypochondriacs.
Sometimes Mr. L would dream longingly of retirement. Although he might miss many of his patients, there were some he’d be happy to see the last of. One such patient was Mr. N, a bachelor with no family who spent much of his time alone and therefore, thought Mr. L, spent far too much time thinking about every ache and pain and imagining the worst. The patient had first come in for an appointment at age 45, concerned about his frequent urination. He was diagnosed with prostatitis and began coming in often over the next several years with complaints of urgency incontinence, leaking, and frequent urination. He would recount at great length each bout of incontinence, each episode of leakage. He kept lists of how often he was urinating. Mr. L prescribed various medications, with little lasting effect.
When Mr. N came in for appointments, he always had lengthy, typed lists of questions to ask Mr. L. The clinician would often find himself tapping his foot impatiently as Mr. N unhurriedly—in fact, at a snail’s pace—described every detail of every complaint that he had. No twinge was too insignificant to mention. Mr. L imagined the waiting room filling up, then overflowing, as all his time was spent calming Mr. N’s anxieties. Mr. N always expected the worst, and would pepper Mr. L with questions as to whether he might have cancer. The clinician told him that it was highly unlikely, seeing as Mr. N was young and had no family history. His prostate-specific antigen (PSA) was measured at 1.9 ng/mL, which Mr. L assured him was normal.
Over the next four years, Mr. N came in repeatedly with extensive descriptions of his continued urinary difficulties and related anxiety. Mr. L sighed to himself and nodded at the patient while thinking primarily about the pileup in the waiting room and how the other clinicians would be frowning at his inability to keep the appointments on schedule. In frustration one day, when Mr. N was slowly reciting how many times he had urinated over the past month, Mr. L wrote, “It’s all crap” in the patient’s chart. Yet he did order another PSA for Mr. N. This time the patient’s PSA had increased to 4.0. The patient expressed concern, but Mr. L calmed him down and told him that a level of 4 was “not worth getting excited about.” Mr. N continued coming in regularly for another year, at which point Mr. L decided to retire.
After Mr. L’s retirement, Mr. N switched to another urology practice. His new physician obtained a PSA level of 3.5 and noted that this was very elevated for a man of Mr. N’s age. The new doctor ordered an ultrasound with biopsy, and diagnosed Mr. N with moderately and poorly differentiated adenocarcinoma of the prostate. More than a year later, Mr. N was diagnosed with metastatic prostate cancer.
Mr. N was furious. He immediately consulted a plaintiff’s attorney to explore whether he had a case. “I went to Mr. L for seven years,” he told the attorney, “and he never ordered a biopsy, even when my PSA was 4. He barely listened to me!”
The attorney hired an expert who read the records and contended that a doubling of the PSA in a man with urinary symptoms is suggestive of prostate cancer, and that Mr. L should have ordered an ultrasound and biopsy when the second PSA results were obtained. The tests would have detected the cancer at a curable stage. “It’s likely,” said the expert, “that the patient will die from the cancer, and this is a direct result of Mr. L’s negligence.”
The attorney took on the case and Mr. L was notified that he was being sued. It was a shock to be jolted out of retirement by a lawsuit, and even more of a shock to discover that Mr. N had been right about his concerns all along. The retired clinician began reassessing his decisions as well as how much credence he had given to Mr. N’s complaints. Mr. L felt guilty, and couldn’t muster up the fortitude to take the case to trial. Both sides sat down to settlement discussions, and the case was eventually settled out of court for $825,000.
Settlement is a viable (and sometimes preferred) option for several reasons. Trials are extremely costly in terms of time, money, and stress endured by the parties involved. The cases often drag on for years, hanging like a dark cloud above the litigants. And in a case like this, in which Mr. L had begun second-guessing Mr. L’s actions and knew that the patient’s chart—with his notation, “It’s all crap”—would be admitted as evidence, settlement was probably the best option. Even an open-minded, unbiased jury would have been taken aback by the note in the chart, and may have become prejudiced against Mr. L in a trial.
All clinicians will, at some point, come across a patient they find disagreeable. The trick is to not let your feelings get in the way of your practice. Mr. L found Mr. N to be annoying, so he discounted the man’s complaints and didn’t assess them the same way that he would a patient he did not consider to be a hypochondriac. And although Mr. L indeed might have felt that the patient’s complaints were “all crap” at the time, writing such a comment in the chart was inadvisable and served no legitimate purpose.
Just as it’s important to take good notes in a patient’s file in order to protect yourself, it is also important to be judicious about what you write. There is no place for extraneous comments in a patient’s file.