Are the Physicians to Blame for the Patient's Failure to Follow Up?

Jacqueline Ross, PhD, RN, CPAN

Disclosures

September 20, 2021

It's not uncommon for physicians to encounter a patient who fails to return for a follow-up appointment. As this case shows, simply "making the effort" to reach patients who don't show up is not always good enough. Physicians are wise to go a step further with nonadherent patients.

A 49-year-old patient presented for a routine screening mammogram. The patient had a history of smoking and a family history of breast cancer. The radiologist who read the mammogram noted that the study was not complete due to density of breast tissue and recommended additional studies. He recommended additional imaging to evaluate a density in the right upper breast.

One week later, a second mammogram was performed. The second radiologist noted very dense tissue but no evidence of malignancy. No follow-up was recommended.

One year later, the patient presented to her gynecologist with a complaint of a breast lump. The gynecologist ordered bilateral mammograms and right breast ultrasound. The third radiologist reported mildly asymmetrical breasts with numerous small cysts. He also noted increased density in the upper outer quadrant of the right breast but did not identify any suspicious nodules. The radiologist advised follow-up studies in 1 year.

The patient did not return for 3 years. The gynecologist and radiology department sent letters recommending follow-up studies, but the patient did not respond.

The patient then presented to urgent care with severe back pain, shortness of breath, and chest pain with deep breathing. A chest x-ray noted clear lungs but identified osteolytic lesions on the spine. A biopsy showed metastatic breast carcinoma. The patient died 2 years later.

A claim was filed against the radiologist and the gynecologist.

What Did the Experts Say?

Medical experts for the plaintiff opined that the original mammogram was abnormal enough to prompt an MRI and biopsy. The second year's mammogram was more suspicious of abnormality and included a complaint of breast lump, they said. The plaintiffs' experts also stated that if diagnosed and treated in the first year, the cancer would not have metastasized.

Defense experts determined that the second and third radiologists should have recommended MRI and biopsy, and the gynecologist should have ordered an MRI or biopsy following the second mammogram. The primary concern was the failure to order a biopsy when the patient presented with a breast lump. The dense breast tissue obscured the ability to identify tumors. The defendants settled this case.

This case underscores the importance of ordering repeat studies when initial views are of poor quality or positioning blocks a more complete view. The case also illustrates the potential liability for physicians in instances where patients are noncompliant and ignore follow-up care. The physicians in this case may have fared differently had they sent the patient a certified informed refusal letter. Such letters can aid a physician's defense should a legal claim arise.

This case comes from "Diagnostic and Interventional Radiology Closed Claims Study," published by The Doctors Company.

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