If the condition or symptom is serious enough to address in the course of the visit, it requires the same level of attention as any other presenting problem. When time constraints prevent you from addressing the complaint with the proper diligence, it would be appropriate—assuming the symptom in question is nonurgent—to ask the patient to make another appointment. But be sure to document that you did so.
CASE 2
A 62-year-old man saw his family physician for routine care of hypertension, diabetes, and hyperlipidemia. During the visit, the patient mentioned that he had back pain, insomnia, and a sore tongue, which the physician diagnosed as aphthous stomatitis and for which a steroidal oral cream was prescribed.
The patient was scheduled to return for a routine visit in 4 months, but did not come in until 7 months had passed—at which time the physician noted a >1 cm nodular bleeding tongue lesion. Biopsy showed squamous cell cancer, and the patient required extensive surgery, chemotherapy, and radiation. He sued for misdiagnosis and delayed diagnosis.
The physician’s defense was that given the symptoms and findings, aphthous stomatitis was a reasonable diagnosis and that he had instructed the patient to return to the office if he didn’t feel better in a few weeks. The patient disputed this. His attorney noted that the patient had multiple risk factors for tongue cancer that were not in the medical record; nor was there documentation of a tongue examination or the claimed instructions for the return visit, indicating that the patient received substandard care. The case was settled at trial for $300,000.
Commentary: The contrast between the thorough documentation for the patient’s chronic disease history and physical exam and the absence of documentation for the sore tongue suggests that this was an instance of a “by the way, doc” conversation—and a reminder of the risk that physicians assume when managing patients with multiple conditions.
Diagnostic lesson: The law does not give physicians a pass on the standard of care, regardless of how many conditions are treated in a single visit. To avoid a diagnostic error—and a potential lawsuit—a symptom-specific history, physical, and clear instructions with a follow-up plan are necessary for every condition that’s addressed.
How sure are you of the diagnosis?
It’s human nature to see things in terms of what you’re familiar with. A doctor who has been treating a patient with migraine headaches for years, for example, is apt to assume that “the worst migraine I’ve ever had” is more of the same (CASE 3). Similarly, a clinician who has identified a disorder that matches several of a patient’s symptoms may dismiss or overlook signs and symptoms that do not fit that explanation or diagnosis. Safety advocates refer to this phenomenon as “premature closure.” It may also be a function of overconfidence.
One example of physician overconfidence comes from a study in which experienced dermatologists were asked to examine lesions and diagnose melanoma. Although the specialists confidently diagnosed melanoma in more than 50% of the test cases, 30% of their decisions were later found to be incorrect.19
CASE 3
A 47-year-old man with a history of migraines walked into his physician’s clinic with a complaint of a severe headache. His physician was fully booked but he was given an appointment with a per diem physician. According to the patient and a friend who accompanied him, the patient told the doctor, “This is the worst migraine of my life.” The physician simply documented, “flare of migraine.” The chart indicated that the physical revealed normal vital signs and noted that the patient was “photophobic,” but that his neurological exam was “intact.”
Over the next several hours, the patient received sumatriptan and several doses of opioid analgesics. He stated that he still had a headache but felt better and was sent home with instructions to call or come in if the headache returned.
The next morning a neighbor, unable to reach the patient on the phone, went to his house and found him in a stupor, with slurred speech. The patient was taken by ambulance to a local hospital and found to have a subarachnoid hemorrhage. After weeks in the hospital and a rehabilitation center, he was left with significant cognitive and neurological impairments. He sued for failure to diagnose and won a multimillion dollar award at trial.
Commentary: Expert testimony clearly pointed to the history and physical as being substandard. Specifically, the physical should have included, among other things, a test for nuchal rigidity. Had the patient not had a history of migraines, he might have undergone a more complete medical history and physical evaluation and his symptoms would likely have been evaluated more thoroughly.
Diagnostic lesson: Be wary of “diagnostic inertia”—the tendency to depend too much on a past diagnosis when symptoms arise. Don’t be trapped into attributing all new symptoms to an old disease.