Dr. P, 52, was not an alarmist. In fact, he was known to be a urologist with a particularly calm and relaxing manner who did not order unnecessary tests or procedures.
His patients were generally happy with this. Some of them even sought him out because of his calm demeanor and his attitude of watchful waiting rather than burdening his patients with dire possibilities and numerous tests. His solo practice was quite busy, in part because of referrals by general practitioners who appreciated Dr. P's ability to both help patients physically and also to often help relieve their anxiety.
Complaints of dysuria
One referral was Mr. D, a 48-year-old accountant, who had been referred by his primary care physician for a second opinion. The patient, a married man with a 12-year-old son, had been experiencing urinary issues, which he said were interfering with his sleep and his daily activities.
“Doctor,” Mr. D said, “I wake up a few times a night with the urge to pee, and then when I try to, sometimes I can't that easily, or it hurts. Now I can't sleep because I keep anticipating that I'm going to have to get up, and when I do go to the bathroom, I'm afraid to try urinating because I think it might hurt. What should I do?”
The physician examined the patient, and noted nothing out of the ordinary. Mr. D also complained that he'd experienced flank pain, but did not seem to be exhibiting it during the examination. The referring physician had forwarded the results of a recent urinalysis which indicated microscopic hematuria but no signs of urinary tract infection.
The referring physician also forwarded Mr. D's medical records to Dr. P, and as he looked through them, he noticed that the primary care physician had noted that the patient was suffering from anxiety that might be related to his urinary difficulties. Dr. P agreed with the referring physician, and calmly told the patient that his problem was behavioral and that he needed to learn to relax his sphincter, but that he had no obvious problems or risk to either his upper or lower urinary tract. Dr. P instructed the patient to return if he experienced further problems. The patient appeared very relieved, thanked the physician, and left.
Cystoscopy reveals cancer
Two years later, however, Mr. D returned with similar complaints. This time, Dr. P performed a cystoscopy which revealed a tumor that was diagnosed as late stage muscle-invasive bladder cancer. Despite attempts at treatment, the patient died two years after diagnosis, leaving a widow and a now teenaged son.
On advice from friends, the widow sought counsel from a plaintiff's attorney to find out whether she had a cause of action against the urologist.
“I don't understand,” the widow said to the attorney. “My husband went to Dr. P with the same complaints two years before he was diagnosed with cancer, and Dr. P didn't find anything wrong. But obviously there was. Why didn't Dr. P find it in the first place?”
The attorney consulted with an expert urologist who reviewed the medical records and told the attorney that had Dr. P performed a cystoscopy at Mr. D's first visit, two years before, Mr. D would have had a far greater chance of survival. “The cancer was already there, causing symptoms. Dr. P should have performed a cystoscopy at the first visit,” the expert said. “His not doing so led to a delay in diagnosis that cost this man his life.”
The attorney took the case, and Dr. P was soon served with papers informing him that he was being sued for malpractice. His insurance company provided him with a defense attorney who advised him to wait it out and see if the case was actually going to go anywhere.
The case did, in fact, proceed. It seemed that before Dr. P knew it, he and his attorney were preparing for trial. But even his attorney admitted that a trial would be an uphill battle considering the facts. Jury selection began but before the attorneys began putting on the case, a settlement was reached where Dr. P would turn over his $1 million liability insurance to the plaintiff.
Legal theory
A delayed diagnosis can be as catastrophic to both the patient and the practitioner as a misdiagnosis. A delayed diagnosis means a consequent delay in treatment, which often means that the disease is no longer curable or requires more invasive or painful and difficult treatments than had it been caught years earlier.
One of the required elements of a malpractice case is that there be an injury and that the injury be caused by an act or omission of the physician (by a delay, a misdiagnosis, improper treatment, and so forth). In cases such as this one, where the delay in diagnosis meant the patient did not get treated and was left with a poor chance at recovery, it is not hard for the plaintiff's attorney to prove that the doctor's delayed diagnosis was responsible for the patient's injury.
Protecting yourself
Unfortunately, this case is a good example of the current dilemma about whether physicians need to practice “defensive” medicine and always run tests. In this case, Dr. P probably should have investigated the symptoms more closely, redone the urinalysis to see if the patient still had microscopic hematuria, and scheduled the patient for a follow-up visit in another week or two to see whether there was any improvement.
If there was no improvement at that point, he should have done the cystoscopy, which would have revealed the cancer. Had the cancer been diagnosed at that stage, the patient would have had a far greater chance at survival.