Dr. Q, 74, was a small-town family practitioner who had worked in the same town for close to half a century. Living and working in a small town meant that the physician often treated families of patients, even several generations of patients.

Such was the case with Mrs. G, 65. Her father had been a patient until his death from cancer 15 years ago, and her two grown sons, and even one grandchild, also were patients of Dr. Q’s practice. Although Mrs. G had spent several years in another state, when she moved back to her hometown she also returned to Dr. Q.

For the past 10 years, Mrs. G came in for regular check-ups and for treatment and monitoring of anemia, which she had developed during that time. Dr. Q did not believe in what he called “unnecessary tests.” His motto was “fix what ails your patients, and don’t cause extra problems.” Other physicians might send patients out for bone density scans, mammograms, colonoscopies, MRI’s, echocardiograms and the like, but not Dr. Q. Not unless he deemed it really necessary.

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A minimalist approach

“Do you know how many false positives come up with things like mammograms,” he told his nurse. “Why put someone through that hell if it isn’t really necessary?” Certainly, Dr. Q agreed that an apparent broken bone required an x-ray. And if a patient had symptoms indicating they required a diagnostic test—a CT scan or endoscopy—they would be referred to get one. But in the absence of symptoms, Dr. Q was not particularly proactive in ordering, or even suggesting, tests for patients.

So, despite the fact that Mrs. G was in her 60’s and had a family history of cancer, Dr. Q did not advise her to get a colonoscopy or a sigmoidoscopy. It wasn’t his general habit to ask about or advise such things during exams. Nor did he perform a digital rectal exam (DRE) on Mrs. G during any of her office visits.

One mid-summer day Mrs. G came in with complaints of fatigue, weakness, and abdominal pain. Dr. Q diagnosed her as having a viral infection, and told her to come back if she did not feel better. Several weeks later, she returned, with similar complaints, and after checking her vitals, the physician still believed she was fighting off a bug. “There’s a lot of that going around,” he said.

Two weeks later, Mrs. G went to the emergency department of the local hospital with complaints of chest pain and shortness of breath. A chest x-ray revealed a large left lung mass, and a CT scan showed multiple liver masses. A liver biopsy revealed metastatic cancer suggestive of primary colon cancer.

A colonoscopy performed a week later revealed a large colon tumor. The treating physicians in the hospital felt that the cancer had originated in Mrs. G’s colon and spread to her lungs and liver. Exploratory surgery revealed that much of her abdomen had been replaced by cancerous tumors. The patient was left with no treatment options due to the extent of the spread of the cancer. All that could be done for Mrs. G was to give her continuous pain medication until she died, a mere two weeks later.

Her family was stunned. Mrs. G had been “fine” at the beginning of the summer, yet was gone before the end of it. As the shock faded, it was replaced with anger. Why, they wondered, did Dr. Q not recommend that Mrs. G have a colonoscopy? Was that not standard practice? The family consulted an attorney who subpoenaed the medical records, and noted that there was no mention, in 10 years’ worth of medical records, that the physician had advised, or even mentioned, a colonoscopy or sigmoidoscopy. “I believe we have a case,” the attorney said.

Dr. Q was served with papers notifying him that he was being sued for medical malpractice. He met with his defense attorney who warned him that a malpractice trial could be a long and unpleasant experience.

“Should we try to settle?” the physician asked.

“I suggest we go through the deposition stage and see how things look at that point,” the attorney advised.

During depositions, Dr. Q was asked about whether he had ever suggested that Mrs. G have a colonoscopy or sigmoidoscopy. He replied “no.” He was asked whether he was aware that there was a history of cancer in Mrs. G’s family. “Yes,” he said. He was asked whether he had done any screening for cancer in Mrs. G’s case, such as a DRE or breast exam, or whether he had ever recommended that she get such screenings. “No,” Dr. Q admitted.

After several grueling days of depositions, the defense attorney pulled Dr. Q aside and said “I think it’s time to talk about settlement offers. I don’t think this will play out well in front of a jury.” Negotiations began, and, just prior to the trial starting, the case was settled for the practitioners’ liability limit of $1 million.

Legal issue

Depositions are part of the discovery process. The purpose of depositions is to give both sides a “preview” of what will come up at trial. This is especially important with complex cases. In addition, depositions provide each side with the opportunity to impugn a witnesses’ testimony at trial if he or she says something different from what they said during depositions, which are also under oath.

Protecting yourself

Whether a test is “unnecessary” or not is subject to great debate these days. Some physicians regularly practice “defensive medicine” and order every possible test for their patients to protect themselves from potential lawuits. Unfortunately, this puts a heavy toll on the health care system, and is not necessarily the best solution for all patients.

The biggest failing here was that Dr. Q never even suggested a colonoscopy to Mrs. G. At the patient’s age, and with a family history of cancer, it was a failure on the part of the physician not to suggest that as part of a regular exam. Whether Mrs. G followed up on that recommendation would not have been in the control of the doctor, but the referral would have been.

As part of a regular check-up, always recommend standard, age- and health-history-specific tests that are warranted, such as colonoscopy, mammography, and PSA tests. Notes should always be made in the patient’s file that such recommendations were made. If the patient does not go, you have done your part by informing the patient about the value, and/or necessity, of the test.