A 56-year-old woman came to a pain management specialist in July 2015 for treatment of back pain. The patient had a history of chronic obstructive pulmonary disease.
In August 2015, the pain management specialist ordered an MRI of the thoracic spine. In addition to some spinal pathology, the radiologist noted a “possible 9 mm right lung nodule.” The radiologist recommended a CT scan if clinically warranted.
The patient’s next appointment with the pain management specialist was delayed due to bad weather and scheduling conflicts. She next saw him in October 2015. There was no mention of the pulmonary nodule. Two more office visits occurred that year and 14 visits in 2016. During those visits, the patient saw either the pain management specialist or his advanced practice registered nurse (APRN).
In July 2017, the APRN reviewed the chart and noticed the MRI report. She discussed the MRI results with the patient and told her to discuss them with her primary care physician. The radiology report was faxed to the patient’s primary care physician.
The patient’s primary care physician ordered a CT scan, which revealed a right paratracheal mass. The mass was biopsied and found to be a small cell carcinoma. The patient was treated with chemotherapy and radiation. By March 2018, she was in remission. However, her COPD worsened. She was hospitalized several times in 2018 with weakness, chest pain, and difficulty breathing.
The patient was found dead at her home on April 11, 2019. The cause of death was listed as multi-system organ failure. Lung cancer was listed as a contributing factor. There was no autopsy.
A lawsuit was filed against the pain management specialist, alleging delay in diagnosing the patient’s lung cancer. The plaintiffs claimed the delay reduced the patient’s prognosis for survival and ultimately caused her death.
Although the lung nodule was an incidental finding on the MRI, it was difficult to argue that the pain management specialist did not have a duty to act on the findings by discussing them with the patient, sending them to her primary care physician, and/or ordering the CT scan. The pain management specialist testified that he should have notified the patient.
Defense experts who reviewed this case agreed that he should have notified the patient. However, defense oncology experts argued that the “late” diagnosis did not affect the patient’s prognosis and did not cause her death. The prognosis for small cell lung cancer is poor, regardless of the timing of the diagnosis. This cancer typically responds well to the initial round of treatment, as in this case, but it typically recurs and can cause death within another year. Defense experts argued the patient was in remission and likely died due to an exacerbation of her COPD.
This case was settled on behalf of the pain management specialist.
Risk management considerations
The following processes can help address the potential for an allegation of delay in diagnosis and treatment.
- Develop a tracking system for all labs, diagnostic studies, and referrals. This can be done via electronic order entry in the EHR, or a paper log.
- Initial and date or electronically sign all laboratory and diagnostic reports upon your review of the report. Develop protocols to ensure that documents are not filed before your review.
- Document follow-up actions if abnormal results are noted on the laboratory/ diagnostic report.
- Document the discussion with the patient about diagnostic abnormalities. Each attempt made by a staff member to contact the patient with follow up instructions should be documented.
- Consider a referral to a specialist for questionable diagnoses. Establishing these processes can maximize a physician’s defensibility and prevent a delay in diagnosis and treatment for the patient.