A patient’s off-the-cuff remark as she gets ready to leave can signal a condition more serious than the original complaint.

Dr. W, 45, had been in family practice for 12 years. While he was most comfortable treating adults with chronic conditions, such as diabetes, hypertension, CAD, and hyperlipidemia, his patients came with the usual variety of complaints.

Ms. R was a 46-year-old established patient suffering from an upper respiratory tract infection. Dr. W examined her carefully, prescribed symptomatic treatment for her acute illness, and was about to conclude the visit, when she hit him with “By the way, Doctor.” She said that for the past week she had noticed a discharge and crusting around her left nipple.

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Dr. W regrouped. Her remark meant Ms. R would have to undress again, put on an examination gown, and be examined with the nurse present. That meant another 20 minutes out of a busy day — and he was behind already.

The doctor sighed and went on to his next patient while Ms. R prepared herself for the “by the way” exam. When he returned, Dr. W found a crusted rash on the left nipple. He prescribed 1% cortisone cream and advised Ms. R to return if the rash did not heal in a week or so.

A startling request

Six months later, Dr. W was startled by a request from a plaintiff’s lawyer for Ms. R’s medical records. He asked his office nurse whether she had heard anything through the grapevine. She replied that she had heard Ms. R had had a radical mastectomy and was receiving chemotherapy for carcinoma of the breast. A chill ran down Dr. W’s back.

He reviewed his records, which described the crusting on the nipple and saw, with some satisfaction, this entry: “RTC if not impr 1 wk.” In his subsequent deposition and testimony before a jury, he would interpret the notation to mean: “Return to clinic if not improved in one week.” He’d also noted from his records that the patient had not returned.

Undiagnosed Paget’s disease

As Dr. W feared, a month after the call for records the plaintiff’s lawyer filed a lawsuit against him for malpractice. The court papers alleged “flagrant substandard care that caused severe damages to [the patient].”

Expert witnesses for both the plaintiff and the defense were soon testifying to directly opposite views of the case. The plaintiff’s expert said that if Dr. W had suspected Paget’s disease of the nipple and referred the patient to a specialist at that point, she would avoided a radical mastectomy, instead undergoing a quadrant resection of the breast or a simple mastectomy. The defense expert testified that because of the natural history of Paget’s disease of the breast, the probable outcome would have been the same, even if Dr. W had made the diagnosis on first presentation.

Despite attempts at settlement, the case proceeded to trial almost two years after it was first filed.

At the trial, Ms. R testified about first learning she had breast cancer and her decision to have a radical mastectomy. When the defense lawyer asked, “Why didn’t you return to the clinic as instructed by Dr. W,” she answered, “I don’t remember his saying that.”

That statement turned the rest of the trial into a credibility contest. In the end, Dr. W’s clinical notes won out. The patient was awarded $135,000, but a 50% comparative fault that reduced the award by half. Dr. W returned to his practice, newly aware of the importance of clinical notes in his risk-management program.