A lesson in Legal Medicine
Unintentional Comments …Undesirable Results
M. P. Ravindra Nathan, MD, FACC
Brooksville, FL
A long-established relationship with a patient and a good rapport with the family can save your neck in a crisis. On the other hand, a very enthusiastic academic colleague who tells the patient and relatives that a finding was missed in a previous X-Ray can pave the way for a malpractice suit. The story of Robert Townsend and his wife Melanie (not their real names) is a classic example.
Robert, aged 73 years, had been a patient of mine for nearly 15 years. A photographer by trade, he would sometimes oblige me by taking pictures of my children or the office staff and Melanie and I had become good friends as well. His mild hypertension was well controlled on medications. One day he presented with palpitations and the EKG showed atrial fibrillation. The diagnosis was ‘sick sinus syndrome’ with tachy-brady arrhythmias. A permanent pacemaker was implanted and along with medications, he remained well.
Robert came regularly for his office follow up and occasionally needed treatment for respiratory infections. He had been a heavy cigarette smoker in the past, but had cut down recently and exhibited no lung problems. Then Robert needed a left carotid surgery for symptoms of a mini stroke.
About 10 months prior to his final admission, Robert had an episode of syncope. The cardiac work up was essentially negative, pacemaker tested normal and the chest-X-Ray unremarkable. But he had developed a right carotid stenosis this time for which he promptly underwent surgery. Once again, he was back to his usual self and resumed his work.
One day, he presented to the emergency department (ED) with sudden left sided chest discomfort which subsided with sublingual nitroglycerine. I had seen him in the office only 2 weeks before, with an acute bronchitis and was treated with antibiotics, resulting in full recovery. So I was surprised to see him in the ED. Clinical examination was unremarkable but the chest X-Ray report said, “hyper-inflated lungs with some infiltrate in the left hilar area.”
The working diagnosis was most likely a pneumonia and COPD. With intravenous antibiotics and fluids, he improved. A pulmonary specialist was consulted and he worried about the possibility of a left hilar tumor. CEA was 130, slightly elevated. Although the bronchoscopy showed no endobronchial lesion, a CT scan of the chest revealed 7 cm mass in the left hilum and hilar adenopathy, suggestive of a tumor.
A thoracic surgeon, Dr. T, was consulted. The surgeon went back and looked at the chest x-rays taken 10 months ago and determined that there was, indeed, a small infiltrate in the left hilum which most likely represented the beginning of the tumor, although the radiologist had reported “no significant abnormality.” He showed both the films to Melanie and discussed these findings and she became upset. During the next visit to my office, she brought the films for my review, put them up on the view box and pointed at the shadow: “See this, that’s where Dr. T said was the ‘beginning of the tumor’ a year ago.” Hindsight being 20/20, if you put both films side by side, one could conceivably argue that there may have been a very soft, relatively inconspicuous shadow in the first film, which the radiologist had overlooked.
Robert underwent a left thoracotomy which showed a large left hilar tumor with invasion of pericardium and needed extensive surgery – resection of the tumor, attached phrenic nerve and part of the pericardium with reconstruction, but died after a stormy post-operative course.
The wife sued the radiologist who interpreted the x-rays and the hospital, based on the surgeon’s comments. The discovery process continued for two years. They scheduled two depositions for me but the lawyer kept postponing. I dreaded them even though I was not the one being sued. But there is always the fear that after the depositions, the lawyer can change his mind and include you in the suit as well! Plus they could put both X-Rays on the view box and ask me if I would have diagnosed this earlier and thus could have prevented a delay in treatment.
Then one day, as I walked into my office, Anita, my office manager announced, with a grin on her face, “Hey, you don’t have to go for the deposition, are you happy?” The plaintiffs and the lawyers settled the case out of court for an undisclosed amount.
I reflected on the case and the development of the events for a long time. Although it is easy to be a good ‘Monday morning quarterback’, I personally couldn’t fault the radiologists. I had discussed the X-Rays with both the radiologists after the wife brought the two films for my input. They said, “No, it would have been extremely difficult to diagnose this lesion earlier; it is easy when you have a subsequent film to compare.”
Sometimes our words can come back to haunt us. Had the surgeon been a little more discrete, perhaps this legal wrangle could have been avoided. One has to be very careful about what you say to the patients, especially if you imply that an error was committed by another doctor. I wondered what happened to the old adage, “Speak no evil,” especially if it didn’t serve any purpose as in this case at such a late stage.
It was certainly a relief that I was not sued, although I felt sad for the radiologists. Part of the reason for not including me in the suit was probably that I had a good rapport with the wife and had taken care of both of them for many years. And I certainly didn’t feel responsible for any errors in the radiological interpretation, if indeed there was any. Normally I do look at all chest X-Rays and, the one in question taken 10 months before the final diagnosis, looked normal to me too. Only by comparing one with the other, one would have been able to see the difference – truly a retrospective diagnosis. But we all know that because of the grave implications, any missed cancer is an automatic liability risk.