Mr. B, a 34-year-old physician assistant, was having another frenetic day in the gastroenterology clinic, and he was not happy. When he had taken the job a year ago, he had hoped it would broaden his knowledge, enhance his professional standing, and allow him to use his counseling skills.
Instead, he felt he was slaving away in a co-lonoscopy mill. Dr. M, the head gastroenterologist, prided himself on his speed in performing the procedures. “I regularly do 30 or more a day,” he’d brag. “Once, when my partner was sick, I did 50!”
Dr. M expected everyone in the practice to act with similar speed and efficiency. The result was a lucrative but frantic clinic.
Mr. B was halfway through a hectic morning when he met a new patient. Glancing at the referral note from the man’s primary-care physician, he saw that Mr. Y was 42 years old and had been experiencing right-sided abdominal pain, constipation, and fatigue. A fecal occult blood test (FOBT) more than a month before had been positive, but an abdominal x-ray had been normal.
Taking a history, Mr. B noted that Mr. Y had had ulcers as a child and that his current abdominal pain was intermittent, usually occurring after meals. Nonetheless, Mr. B did not perform a new FOBT to assess whether Mr. Y continued to bleed or a rectal exam to evaluate whether hemorrhoids had caused the positive test. Instead, he told the patient to come back in two months, and Dr. M would perform a colonoscopy.
When Mr. Y returned as scheduled, Mr. B’s notes from the initial consultation were in the chart. Dr. M neither took a new medical history nor performed his own physical exam. In fact, he did not speak with his patient at all until after the eight-minute procedure was over.
“Entire exam normal,” Dr. M wrote on the chart. Mr. Y went home relieved—for a time.
He returned two months later for a follow-up consultation that lasted a total of four or five minutes. Dr. M noted that Mr. Y’s constipation was “better” after he began taking a fiber preparation but that the patient still reported lower right-quadrant pain. “It’s probably just transient gas,” Dr. M stated. “It will pass.”
Mr. Y went home believing that, whatever his stomach problems might turn out to be, they werenot life-threatening. Seven months later (i.e., nine months after the colonoscopy), Mr. Y was hospitalized for severe anemia that turned out to be the result of steady bleeding caused by cancer of the cecum. By the time a second colonoscopy had been performed and the cancer was discovered, it had reached an incurable stage.
Faced with his impending death and concerned for his wife and two young daughters, Mr. Y consulted a plaintiff’s lawyer. “This should have been caught earlier,” he told the lawyer. “If it had, I think I would have had a chance to survive.”
The attorney hired an expert gastroenterologist to go over Mr. Y’s chart. When that physician confirmed Mr. Y’s suspicions, the attorney filed a malpractice suit against Dr. M, Mr. B, and the clinic.
In preparation of his case, Mr. Y settled into his lawyer’s office to check his chart for accuracy.
“Wait a minute,” he said, almost immediately. “Something is wrong here. I told Mr. B that my grandfather died from colon cancer, but here he’s checked off ‘no’ under ‘family history of colon cancer.’ ”
At his deposition several months later, Mr. B admitted that he had been rushed during the initial exam. He couldn’t specifically remember asking Mr. Y about a family history of colon cancer. When asked if knowledge of a family history would have changed the way he handled the case, Mr. B grudgingly conceded he would have scheduled the colonoscopy sooner and probably have done another FOBT.
Dr. M was deposed next and admitted he never looked at Mr. B’s notes. He explained how the entire colonoscopy had taken eight minutes: two minutes for the anesthesia to take effect, three to insert the scope into Mr. Y’s colon, and three more to examine the colon as the scope was being withdrawn.
The plaintiff’s expert gastroenterologist followed. He asserted that a three-minute examination was “grossly inadequate for a colonoscopy,” constituting only half the minimum standard of care.
The expert also maintained that if Mr. Y’s cancer had been discovered at the time of the first colonoscopy, it probably would still have been treatable. As it was, he predicted the patient had only 12-24 months left to live.
“Mr. Y was never properly examined or treated at the clinic,” the expert concluded. “Dr. M and Mr. B missed obvious warning signs of colon cancer. Especially in the case of such a young person, these signs should have been taken very seriously. Mr. Y had classic symptoms: family history, change in bowel habits, fatigue, blood in the stool, and abdominal pain. What more did these clinicians want? A neon sign!?”
After the expert finished his testimony, the defense lawyers huddled in the hallway with Dr. M and Mr. B for a half hour. They returned to the deposition room with an offer of $2 million to settle the case. Mr. Y accepted.
The discovery process allows attorneys for both sides to access medical records, charts, notes, and documents. Sometimes what’s not in the chart is as important as what is.
In this case, the PA neglected to note a family history of colon cancer, and neither he nor the physician bothered to carefully read the chart. Had they done so, Mr. Y’s age and symptoms, combined with a positive FOBT, should have prompted a much more careful examination.
In today’s managed-care environment, time is often at a premium. Medical practices have to run like businesses, and to protect the bottom line, many patients must be seen each day. But, as a clinician, you must give all patients your full attention during every appointment—even if the time you’re able to spend with them is short.
That means reading the case notes from previous visits and from other clinicians, listening to the patient’s complaints, performing the appropriate exams, and taking adequate notes. Then you have to carefully assess all the information and decide what action might be necessary. Even if you do miss something, if the patient sees that you are attentive and focused, you may be less likely to be sued later on.
If you feel that you have seen too many patients and you can’t give someone your full attention, tell your supervisor. Chancing a mistake that could impact a patient’s health—and incur liability—in order to squeeze in an extra appointment is not worth the risk.
Ms. Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, N.Y.