A 64-YEAR-OLD MAN WAS REFERRED TO A PULMONARY SPECIALIST in January by his primary care physician after a computed tomography (CT) scan showed a spiculated density adjacent to the right main-stem bronchus, a prominent right hilar lymph node, and a noncalcified nodule in the right middle lobe.
Before examining the patient, the pulmonary specialist ordered a positron emission tomography (PET) scan, which he interpreted as showing no significant uptake. He attributed the prominent lymph node to bronchitis and ordered surveillance at 3-month intervals.
A CT scan ordered by the pulmonary specialist in May showed no change, but the radiologist noted that “the possibility of malignancy cannot be excluded.” When the patient saw the specialist in early June, the doctor recommended another CT scan in 3 months.
The patient didn’t return to the specialist until September of the following year. By that time, a CT scan taken a couple of months before (June) as part of preoperative clearance for knee surgery showed that the irregular mass had grown significantly since the CT scan in May of the previous year. A bronchoscopy done in September to evaluate the mass was negative. In November, a lymph node biopsy revealed that the patient had metastatic lung cancer. He died about a month later.
PLAINTIFF’S CLAIM Because the patient was a smoker and the CT scan showed a density, the suspicion for cancer should have been high. A specimen should have been obtained to rule out cancer.
DOCTORS’ DEFENSE The pulmonary specialist followed the correct protocol; failure to diagnose cancer at the September visit didn’t affect the outcome because the cancer was already metastatic and incurable. The patient didn’t quit smoking or follow up regularly with his primary care physician. Moreover, the cancer was at least stage IIA when the primary care physician referred the patient to the specialist.
VERDICT Pennsylvania defense verdict.
COMMENT Although a defense verdict was ultimately returned, wouldn’t a “tickler file” or a reminder to the patient (and documentation if the patient failed to follow-up as recommended) have been easier?