A malpractice trial where a physician misdiagnosed gall bladder disease for irritable bowel syndrome
“In his opening statements, Hawkins’ attorney Barry Nace said he plans to prove that if Bosley would have followed a “standard of care,” of which other physicians follow, Hawkins would have averted being subjected to a barrage of medical bills, physical anguish and a loss of income.
Nace argued that Bosley did not properly treat Hawkins’ symptoms. He told jurors Hawkins complained of pain usually associated with gall bladder problems, but Bosley treated him for irritable bowel syndrome instead.
‘His complaints are absolutely consistent with gall bladder disease,’ Nace stated to the jurors.”
What lawyers fail to understand is that diagnosis is easy in retrospect. There are few cases where a complaint is 100% suggestive of a disease – that is why physicians use differential diagnosis. As they say, the only absolute in medicine is that there are no absolutes.
Here are the clinical manifestations of irritable bowel syndrome:
Abdominal pain in IBS is usually described as a crampy sensation with variable intensity and periodic exacerbations. The pain is generally located in the lower abdomen, often on the left side; however, the location and character of the pain can vary widely. The severity of the pain may range from mildly annoying to debilitating. Several factors, such as emotional stress and eating, may exacerbate the pain, while defecation often provides some relief.Patients with IBS complain of diarrhea, constipation, alternating diarrhea and constipation, or normal bowel habits alternating with either diarrhea and/or constipation.
Contrast that with the presentation of gallbladder disease:
The classic attack is described as an intense dull pressure-like discomfort in the right upper or mid abdomen or in the chest that may radiate to the back and the right shoulder blade. The pain classically follows ingestion of a fatty meal (about one to two hours after) and usually does not occur during fasting. However, the pain may be unrelated to meals in a substantial proportion of patients.The pain is often associated with diaphoresis, nausea and vomiting. It is not exacerbated by movement and not relieved by squatting, bowel movements, or flatus. After the attack, the physical examination is usually normal with the possible exception of residual upper abdominal tenderness.
Surely, you can see that there is some overlap between the two symptoms. In these cases, you generally rule out the most serious disease first – in this case, it would be the gallbladder.
The physician tried to rely his clinical acumen to make the diagnosis: “Doctors are not magicians or wizards. They can only base their result on what they hear.”
This got him into trouble by missing the gallbladder disease. It would have possibly saved the patient, and kept the physician out of the courtroom, had he just ordered an ultrasound instead of relying on the history and physical. Chalk up another point for defensive medicine.
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{ 4 comments }
It’s amazing to me that physicians can tell what is and is not malpractice simply from reading a newspaper article. They don’t even need medical records!!!
If one were to post an article about a physician operating on the wrong body part, though, you’d hear a chorus of – “Well, you can’t tell everything from the newspaper. There’s probably much more to the story. Newspapers never report medical stories correctly!”
At least you are consistent with the defensive medicine cry. Of course, in this “litigious environment”, the doc still didn’t order the ultrasound. Hmmm, that seems to cut against your theory that the present climate results in wasteful testing.
Curious JD –
Did you even READ his post. He agreed that the Doc should have done the ultrasound and was thereby defending “defensive medicine.” Your kneejerk response to interpret everything doctors say about other doctors as “covering up” is pathetic.
BladeDoc
If he was arguing that the doctor should have ordered the ultrasound in order to avoid misdiagnosis, it would sound more like an argument that the doctor violated the governing standard of care than a statement about “defensive medicine”.
After all, if the medical test is medically necessary, it is proper treatment and not “defensive medicine.”
This may raise the question of what “defensive medicine” actually is.
We often think of it as “unnecessary tests done in fear of litigation” – but, of course, litigation rarely results from the failure to order a test, it results from the whatever sequellea result from not treating what would have been revealed by the test if it had been performed. If this is so, then the tests that are the product of “defensive medicine” are not medically unnecessary – they are, in the stereotypical case at least, a sginificant contribution to patient care, by allowing treatment of conditions that would otherwise have gone overlooked (and result in litigation).
So what is wrong with “defensive medicine”? Mostly that it results in many tests that do not signal a diagnosis that would have been missed otherwise – and thus do not contribute to care, while running up costs and demand for services.
Here is an interesting question: what is the difference between practicing “defensive” and “non-defensive” medicine? The “defensive” doctor, again in the stereotype case, orders any test that could conceivably be relevant at the drop of the hat – presumably uncovering a larger percentage of those subtle conditions that would otherwise be misdiagnosed, but at great cost and a highly inefficient use of resources. The non-defensive doctor works systematically through the differential diagnosis, ordering only those tests that seem likely to provide the crucial confirmatory/disconfirmatory evidence among possible diagnoses on the list – and presumably, thereby, missing a larger fraction of “bizarre” cases and subjecting patients to longer waits (while working down to the very unlikely portion of the differential diagnosis list), but keeping costs as low as possible and utilizing resources as efficiently as possible.
What is good or bad about either? Obviously, “defensive” medicine is aggressive and, one hopes, more likely to explore and expose every potentiality, though wildly inefficient and highly expensive. “Non-defensive” medicine is methodical, intelligent, and efficient, but requires the patient with an obscure or unlikely presentation to wait longer, suffer longer, and run a higher risk of misdiagnosis.
Which is better? It depends on the relative values we assign to affordability, patient suffering, speed, accuracy, and efficiency.
Why is “defensive medicine” now (seemingly) so common? We have incentivized test-orderers (doctors) to be highly sensitive to the costs of missed diagnoses, and only secondarily to the costs of . . . well, costs.
Why was “defensive medicine” not common previously? Doctors are not trained to practice scatter-shot diagnosis – they are trained to use medical knowledge and science to work through the case presentation intelligently and responsively. Bill-payers (especially third-party) were incentivized primarily to keep costs down, only secondarily (if at all, in the case of third-party payers) to minimize patient discomfort.
What are the consequences of the shift to defensive medicine? It’s costly, but may improve the likelihood and speed of arriving at a correct diagnosis, particularly in the case of obscure or atypical presentations. This doesn’t actually seem like a bad thing, though we demonize doctors for it.
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