What Leads to a Diagnostic Error?
The term diagnostic error is too general to be of much help in explaining a lawsuit.
"It doesn't tell us whether the wrong diagnosis resulted from a lab report that did not reach the physician or if a piece of information was placed in the wrong medical file or if the physician made an erroneous decision that could have been avoided with better training," says Robert L. Phillips Jr, MD, MSPH, Director of the American Academy of Family Physicians' Robert Graham Center for Policy Studies in Family Medicine and Primary Care.
After studying thousands of claims involving primary care physicians, Phillips found that more patients are harmed in physicians' offices or in other outpatient settings than in hospitals and that failure to diagnose cases can occur more frequently in office outpatient settings than in hospitals.
Malpractice lawsuits for diagnostic errors are most often brought for these conditions:
Myocardial infarction. Myocardial infarction (MI) is the top cause of litigation against primary care physicians. More malpractice dollars are awarded for this condition than any other diagnosis, the PIAA study found. Suits are often brought by younger patients with negative cardiovascular histories, normal electrocardiogram (ECG) results, and atypical complaints.
Failure to obtain a complete medical history is a leading cause of missed MIs, says Paul R. Gabel, Vice President for Claims at NORCAL Mutual Insurance Company, a California-based carrier. "Time spent with patients is limited, and some physicians try to pinpoint a diagnosis too quickly," he says. "The patient may complain of epigastric pain that mimics an MI. So it sounds like a GI problem.
"But the patient may have failed to tell the doctor that he had a recent ECG or treadmill test that was abnormal. The physician needs to be more thorough in asking if the patient has seen other physicians about this condition," says Gabel.
Physicians need to take the time to document the characteristics of chest pain, evaluate risk factors, and give the patient explicit instructions on when reevaluation is needed. Although there are no guarantees that this will avert all lawsuits, it's always important to follow this standard risk management advice.
Breast cancer. Breast cancer is another top cause of claims for failure to make a timely diagnosis. The typical allegation is that the physician didn't recognize the significance of a breast lump or that tests and follow-up were mismanaged.
"Through testing or referral, physicians must rule out the most serious potential condition," says Alfred Belcuore. "The classic example is a woman who goes to her doctor because she felt a lump. The physician's judgment is that this is a cyst and nothing to be alarmed about. Merely reassuring the patient without a clear follow-up plan for monitoring changes leads to lawsuits.
"If the condition turns out to be more than just cysts, the primary care doctor will be on the line for failure to rule out breast cancer. The safest course is to order a mammogram or refer to an OB/GYN for more study."
Relying on mammography alone, with its high rates of false negatives -- up to 20%, according to the National Cancer Institute -- is another pitfall. Physicians may need to observe the patient for a period of months and consider recommending a needle biopsy if the lump is still present. The lesion should be followed through to diagnosis, he says.
Lung cancer. Lawsuits often allege that the physician missed the importance of a symptom, such as recurrent upper respiratory tract infections, chest pain, and cough, and didn't order chest x-rays and computed tomography scans in a timely manner, say risk managers. Patients with risk factors such as smoking should be screened, and physicians must note and respond to any changes in the films and in the patient's symptoms. Failure to do follow-up imaging after a case of pneumonia is often the basis of a lawsuit, say plaintiffs' attorneys.
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Cite this: Mark E. Crane. Six Top Malpractice Risks in Primary Care - Medscape - Sep 14, 2010.