Clinician Fails to Follow Up on Crucial Information

The physician assumed the hepatitis B had resolved
The physician assumed the hepatitis B had resolved

Health care practitioners are privy to a great deal of information about their patients, including information gained from test results, lab work, conversations with patients, and even the basic paperwork that new patients fill out. Knowing what to do with this information, and when to act on it, is crucial. This month's case examines a situation where a physician did not act on a bit of information that he should have taken quite seriously.

Dr. R, 62, was a primary care physician with his own solo practice in a suburban area. He had been located in the same spot for over two decades and had patients who had been with him for even longer. He prided himself on being a caring practitioner who knew when to treat a problem and when to refer it to a specialist. He had never been sued, and was well respected in the community.

One of the physician's long-term patients was Mr. W, 70. Mr. W was an Asian man, who had been born in Hong Kong, and immigrated to America in his mid-20's. He married and had three children, and eventually he and his wife moved to the town in which Dr. R practiced.  Mr. W first became a patient of Dr. R about 15 years ago, when he was in his mid-50's.

At his first appointment, all those years ago, the patient filled out a new patient form which included a checklist of diseases. Among the things that Mr. W had checked off (which included borderline high blood pressure, need for corrective lenses for vision, and acid reflux) was a history of hepatitis B. When asked about it, the patient told Dr. R that he'd had hepatitis as a teen, perhaps 40 or more years ago. The physician took this to mean that the disease was resolved, and made no further notes about it.

Over the past 15 years, the patient had come in fairly regularly for annual exams, and occasional minor health issues, including bronchitis and seasonal illnesses. Mr. W, now 70, was slowing down a bit, but still ran a thriving family business. Aside from his blood pressure, which was now being controlled with medication, and slightly elevated blood glucose numbers (for which the physician advised him to cut down on the junk food), Mr. W seemed relatively healthy at his last exam, a few months before.

But as soon as Dr. R saw him in the waiting room, he knew something was very wrong. The patient had a yellowish tinge, indicating jaundice, and was complaining of abdominal pain. The physician, concerned with the patient's appearance, told him to go to the emergency department for immediate treatment, including an abdominal scan.

According to Mr. W's wife, the jaundice and pain had come on in the last few days – prior to that, her husband had been fine.

At the hospital, Mr. W was put through a battery of scans and blood work. The scans showed that Mr. W was suffering from advanced liver cancer, which had metastasized. The blood work showed, among other things, that Mr. W was positive for chronic hepatitis B.

Dr. R felt terrible when he found out about the patient's cancer diagnosis. After a few rounds of chemotherapy and an attempt at a surgical resection of the liver, it was apparent that nothing could be done for the patient at this point. The cancer was too aggressive. Mr. W died six months after the discovery of the cancer.