Delay in obtaining colonoscopy

Presentation
A 47-year-old woman with a history of anal cancer and surgery three years earlier was referred to Gastroenterologist A. She reported vaginal bleeding with sexual intercourse and lower abdominal cramping.

Physician action
The first visit with Gastroenterologist A on November 6. He performed a rectal exam and found no masses. He ordered a CT scan to rule out recurrence of the anal mass, and indicated that he planned to perform a colonoscopy later. He charted that he planned a follow-up appointment, but the patient was not given an appointment date and she was not called to arrange a follow-up appointment.

The CT scan was completed on November 11, and the report was sent to Gastroenterologist A’s office. It stated, “a partially necrotic mass involving the left posterior wall of the rectum is suspected.” The radiologist recommended confirmation with barium enema and/or colonoscopy. The mass was reported as being 4 cm in length, located 6 cm from the anus. While Gastroenterologist A agreed that the report was received in his office, for unknown reasons, the patient was not contacted about the results or to arrange an appointment.

The patient returned to Gastroenterologist A on May 29 reporting a 3-day history of lower abdominal pain, nausea, and frequent bowel movements. He examined the patient and found her to be pale with no cardiovascular, chest, or abdominal abnormalities.

His impression was possible recent small bowel obstruction, anemia, and need for a rectal examination. He planned to obtain a colonoscopy, CBC, repeat CT scan, and possible small bowel follow through. Gastroenterologist A did not discuss the November 11 CT scan results with the patient or recommend the follow-up outlined by the radiologist.

Gastroenterologist A’s notes indicated the patient was called on June 5, and she reported feeling well. A comment, “awaiting colonoscopy”, was documented. Gastroenterologist A advised that he made this call to the patient after receiving some lab results. The patient was scheduled for a colonoscopy on June 18, but according to the patient, was not told she needed the colonoscopy urgently. The patient cancelled the June 18 colonoscopy due to travel plans.

The patient tried to reschedule the colonoscopy in August, but was told they were not scheduling colonoscopies due to localized flooding of hospitals in the area. Gastroenterologist A next spoke to the patient by phone, and she reported loose stools and frequent bleeding. The chart note for this phone call stated, “I do not know why she has delayed colonoscopy.” According to the patient, Gastroenterologist A became very angry with her during the phone conversation and yelled at her for not having the colonoscopy. Following that conversation, the patient decided to seek care from another gastroenterologist.

The patient saw Gastroenterologist B on September 17. He examined her and found her abdomen distended and slightly tender. Her H & H was 6.7/21.9. Digital rectal exam revealed a palpable tumor that he described as fixed, circumferential, and very firm. A CT scan performed on September 19 revealed a large rectal mass and lesion in the right lobe of the liver. (The liver lesion was not present on the November 11 CT scan.) The rectal mass was reported as being larger than on the previous CT scan.

The patient was hospitalized, and a diverting colostomy was performed. The patient then underwent chemotherapy resulting in a reduction of the tumor size. Abdominal surgery occurred on March 29 consisting of resection of the distal sigmoid colon and rectum with hysterectomy, upper vaginal resection, and partial resection of the sacrum. A biopsy of the liver lesion did not indicate the presence of cancer.

At the time the claim was filed, the patient had experienced no recurrence of cancer. However, she does have a permanent colostomy, loss of sexual function, and urinary incontinence.

Allegations
A lawsuit was filed against Gastroenterologist A, alleging negligence in failing to note and report the results of the CT scan. It was further alleged that Gastroenterologist A’s failure to initiate follow-up treatment resulted in the patient having to undergo more extensive surgery.

Legal implications
The plaintiffs retained testimony from credible experts to support the allegations. Their gastroenterology expert stated that the defendant fell below the standard of care in failing to advise the patient of the CT scan findings and failing to perform or refer the patient for a biopsy of the mass.

Also testifying for the plaintiffs was the patient’s treating surgeon. He stated that the patient’s surgery was much more extensive as a result of the delay, necessitating a hysterectomy, partial removal of the vagina, partial removal of the sacrum, and development of permanent urinary incontinence. He also testified that, although unable to support his opinion with literature, common sense indicated the patient’s chance of survival was reduced by the delay in diagnosis.

The defense was unable to retain expert support for Gastroenterologist A on standard of care issues. Specifically, defense consultants advised that the standard of care required the results of the November 11 CT scan be relayed to the patient, and the recommendations discussed with the patient.

However, defense experts stated that it was unclear whether or not surgery was more extensive or the patient’s chances of survival reduced as a result of the nine-month delay. One surgery expert stated that the extent of the surgery probably was not increased as a result of the delay. Although testifying for the plaintiffs, the patient’s treating surgeon stated the patient would have required a permanent colostomy even if the cancer had been diagnosed in November. Essentially, the issue of whether or not the patient’s surgery was more extensive as a result of the delay in diagnosis came down to a debate between “dueling experts.”

Further complicating this case were claims by the patient that “someone” in Gastroenterologist A’s office contacted her and told her that the results from the November 11 CT scan were normal. According to the patient, she was told that if the CT scan was normal she should return to her other doctor and undergo pain management.

Gastroenterologist A advised that this is impossible, since no one in his office is authorized to relay results of a CT to a patient, and certainly would not report an abnormal CT as normal. It is his office protocol for a nurse to contact a patient with an abnormal CT scan and schedule an appointment so the results can be discussed in person. In this case, it appeared the patient was not given an appointment and she did not return or ask about the CT scan at future visits because she was allegedly informed everything was normal.

Patient accountability was a factor in this case. The patient did not ask Gastroenterologist A about the CT results during her May 29 appointment. She also delayed the June 18 colonoscopy due to travel plans. Given her history of anal cancer, the argument could be made that the patient should have been more diligent in questioning the physician about her test results and obtaining a colonoscopy.

Disposition
This case was settled on behalf of Gastroenterologist A.

Risk management considerations
Every practice needs a well defined and consistently followed process to verify that test results have been received and acted upon. In this claim, the failure by office staff and the defendant to review the CT scan results and order further tests was not explained. Reports must not be filed in a medical record until the ordering physician has reviewed them and determined the next course of action.

Some patients will not be actively involved in their care. Even if advised to contact the practice in a set time frame, e.g., “call in 2 weeks if you have not been contacted with test results,” some will not comply. It is the responsibility of the ordering physician to have a system in place for follow up to help ensure continuity of care