This doctor prided himself on double-checking radiology reports by reading the films himself. Then he learned that entails liability risk.
Dr. H, 54, is a urologist who works solo and is happy to do so. Earlier in his career he had practiced in a clinic setting, and he considered himself fortunate to have “escaped from the Stalag,” as he put it to his colleagues. Dr. H felt his independence allowed him to pursue a higher standard of care. A wrenching malpractice case put that belief to the test.
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The patient, 66, was referred to Dr. H by his primary-care physician, who had found a PSA level of 9.1 ng/mL as the result of lab work done during a routine physical. The patient reported nocturia and irritative bladder symptoms, and a urinalysis showed microscopic hematuria. The prostate was slightly enlarged, and a culture of the expressed fluid showed E. coli infection.
Prudent study
Dr H. suspected prostatitis, but for safety’s sake he ordered an IV pyelogram (IVP) at the local hospital, which was scheduled and done a week later. The report from the hospital-based radiologist came back after a few days as “normal.” But Dr. H made a practice of reviewing all hospital studies, so the next day he checked the films. He agreed with the radiologist’s reading. Ironically, this review of the films would lead to his involvement in the malpractice litigation.
One year later, the patient re-turned for follow-up. Dr. H noted microscopic hematuria and leukocytes in the urine examination, and found the prostate to be mildly and evenly enlarged. He recommended no further testing on this visit. A year later, the patient noticed frank hematuria, and then asked his family physician to refer him for a CT scan of the kidneys, which revealed renal cell carcinoma, with poorly differentiated cell type. The patient rapidly declined and died a year later from widespread metastases. Shortly after the funeral, the family sued Dr. H for “wrongful death” and “medical negligence.”
During his deposition, Dr. H worked his way through the chart entries, reconstructing his decision-making process at each visit. He summarized the need for an IVP as “conservative medicine” and “safety first,” before describing what he saw when he reviewed the films at the hospital. He explained that the probability of the IVP showing a kidney lesion was low, because of the circumstances and the presence of an alternative explanation for the hematuria. An IVP was indicated at the first visit to rule out renal carcinoma. Because it came back normal, he didn’t consider a repeat IVP necessary when the patient re-turned a year later, despite the hematuria and leukocytes.
The plaintiff expert urologist countered that an IVP was “clearly indicated” for the second visit. He claimed that the first IVP showed a space-occupying lesion intruding on the renal pelvis—an “early sign of renal carcinoma.” Dr. H peered, but he could not see what the expert was describing, even though the carcinoma appeared to come from the same region of the kidney on later studies. The defense expert calculated that the doubling time of the tumor was so short that it probably arose after Dr. H saw the patient for the second time, roughly a year after the first IVP.
The case came to trial after settlement negotiations failed, and the plaintiff lawyer played to the jury’s sympathy: “The patient went to Dr. H with complaints consistent with cancer of the kidney, and Dr. H failed to look at the films closely enough to see what we can all see now—a suspicious lump that called for follow-up and further investigation. This mistake cost the patient his life.”
The trial progressed for five long days, with each of the witnesses repeating the testimony
from their depositions. When Dr. H had his turn, he traced his way through the chart, until the defense lawyer reached the drama-tic point of his case: “Did you, Dr. H, personally look at the films from the patient?” “Yes, I always look at patient films personally. I agreed with the radiologist: the IVP was normal.” The jury brought back a verdict for Dr. H.
