Malpractice Case: When the Care Team Drops the Ball on Documenting

Gordon T. Ownby


January 04, 2019

Medscape Editor's Key Points:

  • Ensure that all members of a patient's care team know who is managing particular aspects of treatment.

  • Be sure you know who is handling tests and other aspects of care.

  • Document all aspects of patient treatment so that everyone knows their job and nothing gets overlooked.

Handoff vs Consult: Know the Difference

When a specialist treats a referred patient, making clear who will be managing particular aspects of the patient's ongoing care can help avoid finger-pointing down the road.

A 61-year-old lawyer began treatment with Dr. IM, an internist, and had a PSA test drawn. Dr. IM telephoned the patient with an elevated result of 7.12 and referred the patient to a urologist. When the patient returned to Dr. IM 6 months later, he reported that he had undergone a prostate biopsy at a cancer center. The result of the biopsy was negative, but he told Dr. IM that his prostate size was 120 g.

Eleven months later, the patient saw Dr. IM for his annual checkup and reported that a second biopsy taken at the cancer center came back negative, save for a few transitional cells. At the next year's checkup, the patient told Dr. IM that he was being followed by his urologist for an elevated PSA of 9.

During the next year's checkup, Dr. IM ordered a PSA, which came back at 6.37. But after another visit to Dr. IM 3 years later (now 6 years since the patient's first visit to Dr. IM), the patient's PSA was 13.2—elevated but within the fluctuation range for benign prostatic hypertrophy. Nevertheless, Dr. IM referred the gentleman to Dr. U, a urologist.

Dr. U performed a cystoscopy and wrote to Dr. IM that the patient's PSA was 17.7 and that a prostate biopsy showed benign prostatic hyperplasia without malignancy. In his letter, Dr. U attributed microscopic hematuria to a transitional cell carcinoma of the bladder, which he resected. Dr. U closed his medical comments to Dr. IM by stating that the patient "will require surveillance cystoscopy" for the bladder, but he did not offer who would be following the patient's prostate issues.

The patient returned to Dr. U roughly every 4 months for cystoscopies. Dr. U did not obtain any PSA levels after the initial consultation, though a draw ordered by Dr. IM the next year showed a value of 8.03. Several months later, Dr. U resected another bladder tumor. When he last saw the patient 2 years after that (which was 3 years after the initial consultation with Dr. U), the patient had no symptoms of cancer.

But 2 months later, during a business trip, the patient experienced extreme pain in his lower back, left leg, and foot. When he returned home, he saw Dr. IM, who ordered a CT, MRI, and a bone biopsy. The bone scan showed osteosclerotic metastases typical of prostate cancer.

In a lawsuit, the patient alleged that Dr. U failed to perform regular rectal exams and failed to order serial PSA tests following his original prostate biopsy. With serial tests, the plaintiff alleged, an elevated PSA would have prompted another prostate biopsy, leading to an earlier cancer diagnosis and treatment.

In his suit, the patient also faulted Dr. U and Dr. IM for failing to communicate with each another regarding his health. On that point, each testified in deposition that they had expected that the other would follow the patient for PSA levels, based on his prior experiences. The patient and Dr. U resolved the dispute prior to trial.

Whether it is reasonable for a specialist to rely on the primary care physician for certain aspects of a patient's condition most likely varies with the circumstances. But making that understanding clear, and documenting it, is the best way to avoid any unmet expectations.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "The Specialist Referral: Is it a Handoff or a Consult?"


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