Episode 115: Action Required

Speaker 1: You are listening to Your Practice Made Perfect. Support, protection, and advice for practicing medical professionals, brought to you by SVMIC.

J. Baugh: Hello everyone, and welcome to this episode of Your Practice Made Perfect. My name is J. Baugh, and I'll be your host for today's episode. Today we're going to cover a closed claim that we're calling Action Required. And to help us discuss this closed claim is Zynthia Howse. Zynthia, welcome to the show.

Zynthia: Hi, J. How are you?

J. Baugh: I'm doing well. It's good to have you here today. Before we get started talking about the facts of the case, maybe you could share just a little bit about yourself.

Zynthia: Sure. My name is Zynthia Howse, and I'm a senior claims attorney with State Volunteer Mutual Insurance Company. Prior to that, I was an educator. But I have thankfully been at State Volunteer for 22 years now.

J. Baugh: Well it's good to have you here with us. Thanks for your experience at State Volunteer. I've been there 20 years, myself. Zynthia and I both work in the claims department. So we're glad to be able to share a closed claim with you today. We'll begin this episode with some background information on the patient. Rose Campbell, a generally healthy 74 year old, had been a patient of family practice doctor, Dr. Morris, for more than 10 years. Although she had tried to quit smoking many times, Rose was a lifelong smoker. She had seen Dr. Morris in the spring of 2014 for a checkup, and had only minor complaints, including feeling tired.

A follow-up appointment was scheduled for midsummer the same year. But due to increasing back problems, Rose canceled the appointment with Dr. Morris, and instead went to see neurosurgeon, Dr. Strong, about her back. So Zynthia, can you share a little bit about that appointment with Dr. Strong?

Zynthia: Sure. So as you said, Ms. Campbell had some back problems. And so, she scheduled this appointment with the neurosurgeon. And after he examined her and he evaluated her back, he felt like she was a candidate for a laminectomy. And so that was scheduled. She was admitted to the hospital. And on admission, she is admitted under the service of Dr. Young, the hospitalist. And so now, we've got three doctors involved in her care. We've got Dr. Morris, her primary care physician. We've got the neurosurgeon, Dr. Strong. And now we have the hospitalist Dr. Young.

And in preparing for this surgery, Dr. Young wanted to clear her. And so he ordered a chest x-ray on her, to provide this clearance. So the chest x-ray was done and the radiologist interpreted the x-ray, and felt like there was either some scarring in her lungs or a neoplasm. And so he recommended that she have a CT of her chest.

J. Baugh: So Rose underwent the laminectomy a few days later, and did well. Later, Rose was scheduled for discharge from the hospital. No CT was ordered on her chest. And, it's important to note that the discharge summary made no mention of the radiologist's findings relating to the chest x-ray. The discharge summary did recommend follow-up with her family physician in one week.

Zynthia: So, yes, J. So she's discharged from the hospital. And so the discharge summary, the x-ray report, and the related documentation that was all sent to Dr. Morris, very appropriately reminded her that she needed to be seen on follow-up. When the staff contacted her and scheduled this appointment, however, Rose said, "No, instead of coming back to you, I think I need to see Dr. Strong, who did my surgery."

So Dr. Morris, in turn, just took those records that had been sent to his office, he noted that he had received them, but they were all just scanned in her electronic medical record. And there was no detail review of the record, no assessment. And so it was just, for lack of a better word, put on the shelf.

J. Baugh: So now over the following months, Rose lived her life as she always had. While being the mother of a son and a daughter, she was not particularly close to her children. Both of her children were adults. They had families of their own, and they both lived in states hundreds of miles away. Rose was an amateur painter, which was a hobby that she enthusiastically pursued. As the months after her disc surgery went by, Rose noticed that the pain in her back was returning.

Zynthia: So now we're eight months post-surgery. And again, her back is hurting. So she's thinking, "Well, I better go see Dr. Strong, the neurosurgeon who performed my back surgery." And she did. And he noted that the pain was getting a little worse, so he ordered some additional radiology studies. And, at that point, it was discovered that there was something eating away at her spine. And he basically noted that she had bone metastases. So now we have gone from what may have been just the lung mass when the radiologist noted something pre-surgery, to now the disease that has spread to her bones, her kidneys, her lungs, her lymph nodes, and her liver. And she has only been given months to live. And so she asked the question to the neurosurgeon, "Who dropped the ball?"

J. Baugh: So at this point, both of Rose's children became involved. They traveled to her home in a rural area of the state, in order to assist her during her last days. Suit was filed naming Dr. Morris and his practice, Dr. Young and his practice, and the hospital, as defendants in the case. It became clear early in the development of the suit that the x-ray reports showing a suspicious lesion prior to the disc surgery was in both the hospital record, and in Dr. Morris's office record. Discovery revealed that Dr. Young had ordered the chest x-ray, and he had received the report. But, he had not attempted to contact either Dr. Strong or Dr. Morris to inform them of either the abnormal finding or the radiologist's recommendation to perform a follow-up CT.

Zynthia: So here we are, and Dr. Morris is a defendant in the case. And it is noted that in his electronic medical record that he had received the report. And so, there's the difficult reality that neither doctor followed up with this patient for almost a year, leading to this disastrous result. Rose, then 13 months after this had been noted, succumbed to her disease. So, J., this is a case that really illustrates the hardship in managing the volume of information that bombards a physician in a busy practice, and the difficult in focusing on critical details that require follow-up. As the ordering physician, Dr. Young had a duty to look for that result of the tests he ordered, and to inform the patient of the results, and to report the critical findings to the patient's primary care physician.

J. Baugh: And as for Dr. Morris, he had a duty to pay attention to the abnormal x-ray report that came into his office, and to contact his patient so that she could be appropriately cared for in a timely fashion. The ball was dropped by both physicians in this case. Both doctors and the hospital settled before trial, with Dr. Young paying the largest percentage of the settlement. So, this concludes the case, and it's obviously a very sad outcome. And I do think there are some lessons to be learned from this. So as we wrap up this episode, Zynthia, do you have any tips that you'd like to share with the listeners?

Zynthia: Well, three things come to mind that really stood out to me, the first being an office systems being in place. It would have been very good if Dr. Morris' office had some way of flagging this patient when they knew that she needed follow-up tests, when she first complained of being tired. And then secondly, when he received the test results that said she needed follow-up tests. When the patient canceled her appointment, there should have been something to flag that follow-up was needed.

The second thing that comes to mind is that there is a duty for the physician to know their medical record. When those test results came in, they should have been reviewed, and then the patient would have received the needed follow-up care. And then the last thing is the danger of operating in a silo. Each physician was doing the proper ordering of tests and making appointments, but no one was communicating with each other. And so, classic case of the patient falling through the cracks.

J. Baugh: Yeah, those are some good points that you made Zynthia. And we do see this in some of the cases that we review. So, this was a good case for us to cover today. It's obviously a very sad outcome, but hopefully, there are some lessons that our listeners can learn in providing care to their patients in the future. So once again, Zynthia, we want to thank you for being with us today.

Zynthia: Thanks for having me.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect. Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast.

The contents of this podcast are intended for informational purposes only, and do not constitute legal advice. Policyholders are urged to consult with their personal attorney for legal advice as specific legal requirements may vary from state to state, and change over time. All names in the case have been changed to protect privacy.