The man’s symptoms were hard to pin down, but no biopsy was ordered for more than a year. By then, the cancer had spread.
Dr. R is a successful urologist who had gathered a wide circle of referring physicians over his 15 years in urologic practice, and he prided himself on his diagnostic acumen. But a missed case of prostate cancer dragged him into a malpractice suit.
The patient was a 58-year-old plumber who had his own plumbing business, which as testi-
mony would later show, brought him over $150,000 a year. He presented to his family physician complaining of perineal pain and urinary frequency, urgency, and nocturia. A digital prostate exam revealed no masses and only mild symmetrical enlargement. His PSA level was normal at 1.1 ng/mL, with free PSA at 0.20 ng/mL (18%). Despite the benign findings, the FP took a urine culture, which turned up an Escherichia coli infection. The FP started the patient on antibiotics. Even though the infection cleared within 10 days, the symptoms persisted.
At this point, the FP referred the patient to a urologist (not Dr. R), who reviewed the results so
far, performed another prostatic exam, and repeated the PSA test, which came back substantially the same. When the patient returned to the FP, he complained of increasing bladder spasms, so the FP prescribed bladder antispasmodics, but without success.
By this time, over a year had passed. With the patient’s repeated and varying complaints, the FP decided to refer the man to Dr. R for a more thorough diagnostic workup. Dr. R confirmed that although the man had post-pubic pain probably originating in the prostate, his examination and PSA were within normal limits. He sent the patient back to the FP. A month later, on the patient’s ninth visit to the family practice clinic, the FP thought he could feel some asymmetry in the prostate. He referred the man once again to Dr. R.
Biopsy is a shock
When Dr. R saw the patient again, he confirmed that the patient’s symptoms were postpubic pain consistent with prostatic pain, coupled with some irritative symptoms such as frequency and urgency. On examination, Dr. R thought there may be slight enlargement on the right lobe of the prostate, so he scheduled a biopsy two days later. The result was surprising: invasive carcinoma with a Gleason score of 7 in two of the sextant specimens. When the patient was informed of his findings and prognosis, he was struck silent for a minute and then responded angrily, “I knew there was something wrong, and I kept on telling you doctors, but you wouldn’t believe me. Now what am I going to do?”
The search for metastatic disease showed bony metastases confined to the ribs and pelvis, and the patient was referred to oncology for chemotherapy treatment. Shortly afterward, a plaintiff lawyer called for the patient’s chart and forwarded it to a legal-expert service for review. The reviewer said the long delay between the onset of symptoms and the needle biopsy constituted malpractice. The plaintiff lawyer promptly sued the FP, Dr. R, and the other urologist.
At the deposition several months later, the patient testified that the “cancer had spread all over,” leaving him only three to five years to live. He estimated his lost yearly earnings at $100,000 and said he anticipated medical expenses of $250,000, but conceded insurance would cover most of bills. His wife testified as to their hardship now that he was unable to work, and how she relied on him for advice and support.
Then it was the doctors’ turns. Each explained his decision process at each step of the way. When Dr. R’s turn came, he told how prostatic cancer can be one of the most difficult diagnoses in urology. His management of the case had not been perfect, but based on the test results and information from the patient, his care was as good as anyone could have provided—certainly not substandard. The experts for both sides testified to completely opposing points of view, while the expert economist for the patient stated that depending on his life expectancy, the plumber’s loss of future earnings was between $250,000 and $1 million. The lawyers failed to settle and the case headed for trial. Even during the trial, efforts to reach a settlement foundered. The jury deliberated for one day, returning a judgment against the FP for $1.3 million but finding the two urologists not to be negligent.
Juries are often uncertain as to how to allocate blame for adverse outcomes in medicine. Expert testimony, intended to help ordinary citizens make up their minds, usually confuses them, and often jurors fall back on sympathy and collective guilt of the defendants as a basis for their decisions.
Because of this, verdicts for the plaintiff often involve all the defendants, even if their involvement was peripheral. In this case, though, the jury found that only the FP was liable. This was a doubly unusual outcome because juries typically hold specialists to a higher standard than FPs, especially in cases of missed diagnoses.
A specialist receiving a referral should take care that the referral agrees in clinical details with the patient’s story, and the specialist should record that in his clinical notes. A different symptom or duration of symptoms than is recorded in the referring physician’s chart or letter will raise later questions if the case produces an adverse outcome.
In this case, the patient’s symptoms seemed to vary over time. By the time of the first referral to Dr. R, irritative bladder symptoms took a second place to retropubic pain. Dr. R was careful to note this in his records, since it differed from what the referring physician had recorded. He obtained the patient’s account of this difference in his symptoms, and was able to bring this complicating feature to the jury’s attention during the trial.