Misread Scans Lead to a Fatal Diagnosis and a Court Case
No one can be an expert at everything. Getting a second opinion is not just for patients – it can be useful for clinicians as well. This month's case examines a situation where a physician could have used another set of eyes.
Dr. D was a 59-year old general practitioner who had recently begun working for a mid-sized family practice. Prior to this position he had been a sole practitioner with his own office, but the headaches of running his own practice had worn on him, and he wasn't sorry to give it up. When he started at the new practice, he was instructed on the office's protocol. Dr. D was shown the in-house equipment and told that taking chest films was standard as part of an annual exam at the practice. As part of Dr. D's brief introductory training at the new practice he was given some instruction on the equipment and reading the films. While it wasn't something he was entirely comfortable with, he understood that it was part of his new position.
Many of Dr. D's patients from when he was a sole practitioner followed him to his new practice. One of these patients was Mrs. W, a 68-year old long-time patient of the physician. Mrs. W had numerous health conditions, including morbid obesity, hypertension, stenosis of the carotid arteries, hypercholesterolemia, chronic obstructive pulmonary disease and a family history of heart disease. Dr. D had been successful in recent years in convincing Mrs. W to stop smoking, but she had a 30-year prior history of tobacco use.
Shortly after Dr. D began with the new practice, Mrs. W came in for her annual exam. As part of the exam, Dr. D took an in-house chest film as per the practice's protocol. He read the film as normal, and did not order follow-up imaging, or have the film read over by a radiologist. Unfortunately, and unbeknownst to the doctor, he missed an early Stage IA lung lesion.
A year later, the patient returned for her next annual exam. Again, the physician took a chest film, and again he missed the lung lesion, which had now grown and metastasized. Dr. D misinterpreted the film as being normal, and didn't seek another opinion.