Personal experience led to the effective treatment of a fellow sufferer, but the clinician was sued anyway.

Mr. B is a family clinician who truly empathized with those who have troublesome hemorrhoids —his own hemorrhoids had made him a minor expert on the subject. Nevertheless, a fellow sufferer sued him for misdiagnosis, claiming that his rectal bleeding was actually due to a colonic arteriovenous (AV) malformation.

The patient was a 53-year-old man who presented with rectal bleeding that left bright red blood on the toilet tissue. Mr. B examined the patient and recognized the presence of external and internal hemorrhoids. A rectal exam found no masses. He prescribed a diet of adequate hydration and high-fiber foods to avoid constipation and relieve the symptoms. He also recommended a stool softener, sitz baths, and a cream for pain and swelling. Two weeks later, the patient noted improvement.

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Over the next three years, the man experienced episodes of rectal bleeding that usually was unrelated to pain and swelling of the external hemorrhoids. On each occasion, the bleeding was temporary and soon stopped. As time passed, however, the patient noted a pattern of more severe bleeding and sought a second opinion from a general surgeon. The surgeon recommended a colonoscopy, which revealed an AV malformation in the upper sigmoid colon.

The lesion was later ablated using a combination of endoscopic suturing, stapling, and cautery.

The patient met with a plaintiff’s lawyer, who filed suit against Mr. B for failure to diagnose AV malformation of the colon, thus causing pain and suffering and mental anguish, not to mention continued bleeding.

At depositions, the patient testified that Mr. B never suggested a colonoscopy or mentioned a possible alternate source of the bleeding. The man grudgingly admitted that his symptoms and bleeding had improved following Mr. B’s treatment but added that the bleeding increased gradually for two years, leading him to seek a second opinion. Mr. B defended his diagnosis and treatment and confirmed that at the first examination, hemorrhoids were the source of the patient’s pain and bleeding. The plaintiff’s expert testified that Mr. B had put the patient’s life in danger by failing to investigate other possible sources of rectal bleeding. The defense expert noted that the bleeding might not have come from the AV malformation, which could have developed after the initial diagnosis. When settlement talks collapsed, the case headed for trial. The plaintiff’s lawyer began with an energetic attack on “incompetent clinicians,” claiming that his client had suffered “major trauma” because of Mr. B’s failure to investigate and diagnose the real problem.

Witnesses for the plaintiff recounted the suffering that he had allegedly endured and placed the blame squarely on Mr. B’s shoulders.

Mr. B felt he had been treated unfairly but kept his emotions in check. His testimony was fair, professional, and empathetic. He took the jurors through his notes and his findings and explained his diagnosis, pointing out the success of his treatment in relieving the patient’s symptoms. He ventured the opinion that the AV malformation might not have been present at the initial examination or, if it was, it was quiescent. He projected an image of quiet professional competence despite his inner turmoil. The jury came back with a decision in his favor.

Legal background

The rituals and formality of the courtroom are supposed to provide an objective atmosphere that removes the influence of individual personalities from the judicial process. In actuality, personalities dominate the courtroom, and much of the jurors’ ultimate decision depends on their impressions of the attorneys and witnesses. In this case, Mr. B was able to impress the jurors with his sincerity and credibility and to convince them that he was a caring, careful, and conscientious clinician.

Risk-management principles

Adequate clinical notes allow the clinician to provide the jury with evidence of considered care. The trick is determining exactly how much information is adequate. With the scheduling pressures of modern practice, providers have a limited amount of time to spend on each patient’s chart. One simple guideline is to ask whether the chart entries would enable you to reconstruct the clinical situation if the factual basis of your management was ever questioned either by audit or by a malpractice attorney. This is a matter of personal judgment and, to a certain extent, individual skill, but remains a pressing problem.

A clinical adage is “When you hear hoofbeats, don’t think of zebras.” More simply, “Common things are common.” Mr. B correctly thought of hemorrhoids to explain his patient’s rectal bleeding. However, he might have considered other causes when bleeding persisted for several months despite relief of hemorrhoid pain. His personal experience with hemorrhoids may have predisposed him to think of this condition before any other. Revising one’s diagnosis remains a challenge for many clinicians. Studies show that once established, a diagnosis tends to persist well past the point at which clinical evidence supports it. Consultation allows a fresh pair of eyes to examine the clinical evidence.