Albuquerque oncologist Barbara McAneny, MD, has a patient in his 30s who experienced rectal bleeding for 6 months last year but didn't see a physician because he was afraid of catching COVID-19. He hoped it was just hemorrhoids.
When he finally came in to see her recently, McAneny diagnosed a large colon cancer. She fears the delay could prove fatal. "We'll do our best to cure him, but I don't know if he'll be treatable," she said. "Six months absolutely can make a difference."
She and other oncologists around the country are seeing many patients in the past few months with advanced breast, colon, lung, and other cancers who were not diagnosed and treated during the COVID-19 pandemic because the patients didn't want to come in, or because medical facilities weren't taking non-emergency or non-COVID patients.
Given that failure to diagnose cancer is among the most common medical malpractice allegations, should oncologists be worried that they are at legal risk?
Pandemic Provides "Safe Harbor"
In a March survey done by medical malpractice insurer The Doctors Company, one third of physicians said they were very concerned or somewhat concerned that malpractice claims related to care during the pandemic will rise.
But in most of these cases, physicians and hospitals have little to worry about in terms of medical malpractice liability, according to veteran plaintiff and defense attorneys and the head of a large medical liability insurer.
"You had people with diseases like cancer not getting care because healthcare systems were overwhelmed," said Sean Domnick, JD, a malpractice plaintiff attorney in Boca Raton, Florida. "Will those lead to successful malpractice lawsuits? Most likely not."
"The risks will be low because it's hard to pin it on the doctor if the patient didn't want to come in or facilities weren't scheduling appointments because of the public health emergency," said Richard Roberts, MD, JD, professor of family medicine at the University of Wisconsin and an attorney who has consulted in medical malpractice cases.
In addition, liability protections enacted in more than 30 states because of the COVID-19 pandemic will help shield clinicians from lawsuits. Those laws generally require allegations of gross negligence or reckless conduct far beyond ordinary negligence, which are hard to prove. But the immunity provisions remain largely untested in the courts, and it's unclear how they will affect cases involving care for conditions other than COVID-19.
Another helpful factor is the widespread public appreciation of the valiant work by healthcare professionals throughout the pandemic, though that halo effect could fade over the next several years as malpractice claims from the pandemic period are filed and tried.
"In many circumstances, the pandemic will prove to be a safe harbor for providers," said Steven Wigrizer, JD, a malpractice plaintiff attorney in Philadelphia, Pennsylvania. "Jurors will be reluctant to impose liability on providers who were doing their best in a global pandemic the world hadn't seen in 100 years."
These predictions from liability experts should reassure physicians who are anxious over reports that many cancer diagnoses were missed as a result of the COVID-19 pandemic.
Still, there are situations where physicians and hospitals could be vulnerable to malpractice claims despite the pandemic conditions. The highest-risk cases are those where patients recognized a potential cancer symptom like a breast lump or rectal bleeding, and tried to visit a doctor's office or hospital, but were told they couldn't be seen.
"Those kinds of cases lend themselves to delayed diagnosis claims," said Richard Anderson, MD, an oncologist who is chairman and CEO of The Doctors Company. "My guess is we will see claims," though he expects a reduced number arising from 2020 care scenarios compared with previous years.
So far, his company has seen 20% fewer claims in 2020, which he said isn't surprising given that the volume of physician and hospital visits plummeted.
Another risky situation is where physicians — particularly primary care physicians but also specialists like gynecologists and urologists — did not inform patients about concerning test results and order a follow-up test or visit. That is dangerous even if the physician did try to schedule a visit but the patient canceled the appointment.
"The jury will ask, 'What did you do to get the patient back?' " said Sean Byrne, JD, a malpractice defense attorney in Richmond, Virginia. "The provider will say, 'I'm sure we called.' But it's a difficult defense to say the patient didn't return the call. I need written proof."
Domnick said failures to follow up on suspicious test results could produce viable malpractice claims, pandemic or not. "The question becomes to what extent doctors will try to hide behind COVID to explain otherwise run-of-the-mill negligence," he said. "We'll have to see how that plays out."
There are also worries about missed cancer diagnoses during telemedicine visits. "On telemedicine, I can't feel a lymph node, I can't palpate a breast mass, and I can't see if someone's liver is enlarged," McAneny fretted. "I think you'll get suits because you'll miss stuff."
One other area of exposure cited by the experts: Radiologists and pathologists could be sued for missing tumors in reading imaging tests. "The COVID-19 demand on resources has been immense," Byrne said. "If that production pressure resulted in any quality loss in testing services, we could see claims."
Patient Protocols Provide Protection
There's no question that cancer screenings dropped sharply during the pandemic. In June 2020, the National Cancer Institute estimated there was a 75% decrease in mammograms and colonoscopies during the first few months of the pandemic. It projected that delays in screenings, diagnoses, and treatment likely would result in 10,000 more breast and colorectal cancer deaths than otherwise expected over the next decade.
Delays of even 1 month in treatment for seven common forms of cancer can increase mortality risk by 6% to 13%, according to a BMJ study last year.
While many medical facilities stopped doing preventive screening tests during the height of the pandemic last year, healthcare professionals still found ways to bring in patients with diagnosed cancers or who were at heightened cancer risk for tests and treatment.
Most facilities convened multidisciplinary tumor boards to decide which patients could wait for treatment, which patients could be maintained on drug therapy, and which ones needed immediate surgery, said Carla Fisher, MD, director of breast surgery at Indiana University in Indianapolis. For breast cancer, they used guidelines from her professional group, the American Society of Breast Surgeons.
Following such protocols for prioritizing patients for treatment during the pandemic should help protect against liability, experts said.
Even if it can be shown that a clinician's negligence led to delayed diagnosis or treatment of a patient's cancer, plaintiff attorneys will be wary about filing such claims. That is because it is difficult in most cases to prove that the delay significantly worsened the course of the patient's disease or the odds of survival. Showing harm may be more possible with certain cancers known to be particularly aggressive.
"The plaintiff attorney will have to get an expert to say that the 3-month delay in getting the patient a mammogram caused her great harm," said Roberts, the University of Wisconsin professor. "But it's hard to calculate that scientifically, and it's really hard to lay that all on the doctor or health system, because they were supposed to lock down during the pandemic."
With patients now feeling more comfortable about coming in for physician visits, Byrne urges clinicians to make a special effort to mitigate potential liability arising from the past year. Physicians should carefully review patients' charts and make sure to catch them up on preventive screenings. Some health systems, like Kaiser Permanente, have been doing proactive patient outreach for cancer screening throughout the pandemic.
"Providers may need to be extra diligent, and consider expanding the exam into a wellness visit and remind patients about cancer surveillance," he said.
Overall, however, the expert consensus is that physicians should focus on providing the best quality care going forward, and not worry excessively about the care they wish they could have delivered over the past year during the extraordinary pandemic conditions.
"Liability risks will be decreased, because state laws have changed and doctors will be cut some slack, not just by judges and juries but by patients themselves," Roberts said. "As you are running down the hall to take care of the next person, don't be looking over your shoulder or you'll run into the wall."
Harris Meyer is a freelance writer in Chicago, Illinois.
Medscape Medical News © 2021
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Cite this: Are Oncologists Liable for Pandemic-Related Treatment Delays? - Medscape - Jul 08, 2021.