Malpractice Case: Beware of the Agreeable, Noncompliant Patient

Gordon T. Ownby

Disclosures

April 25, 2018

The Patient Didn't Keep Appointments

The patient next returned to the clinic some 4 months later, complaining of menstrual irregularity. A colleague of Dr FP saw her that day and again 4 days later, when the physician diagnosed early menopause. She was a "no show" for an appointment 3 months later.

Over the course of the next 2.5 years, the chart shows the patient visiting the clinic several times, with the staff again making appointments for her abdominal ultrasound, which the patient did not keep. The patient repeatedly told the office and doctors that she was very busy and had to make numerous trips abroad.

When the patient finally had an abdominal ultrasound performed (37 months after first ordered), the results showed a 4.8 × 3.8 cm, hypervascular mass in the left kidney suggestive of renal cell carcinoma. Upon receiving the ultrasound report, Dr FP called the patient to discuss the test results and told her she should see a urologist that same day. He gave her the names of two urologists who could evaluate the mass.

Another 5 months passed without a visit to a urologist. An abdominal MRI, however, showed a solid left intrapolar renal mass with hypernephroma. The radiologist noted no renal vein invasion, but two right lobe lesions. The differential diagnosis was benign hemangioma versus metastasis.

At a visit to the clinic four days later, the patient discussed her examinations with Dr FP's colleague. The patient told the physician that she would proceed with a urologist and oncologist at a university hospital. A subsequent lab report from the hospital showed left kidney chromophobe renal cell carcinoma stage III, with one lymph node involved.

Patient Sues for Delayed Diagnosis

The patient underwent a nephrectomy and sued Dr FP and the clinic for delayed diagnosis of her cancer. Though acknowledging her client's own inaction, the patient's attorney criticized Dr FP's lack of "written or oral policies, procedures or a custom and practice for documenting conversations with patients about life-threatening illnesses." The attorney claimed that Dr FP should have referred the patient to a urologist after the initial test results.

The parties reached an informal resolution of the case.

In this case, office protocol (since changed) appeared to distinguish between patients who refuse to undergo a test versus those who simply delay action. It may not be the confrontational patient who is a danger to her own health, but the charming one.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories.

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