A cancer missed, who’s responsible for telling the patient?

Amy Tuteur’s father tragically passed away, but could it have been prevented?

She recounts the story, where, after presenting coughing up blood, her father was then diagnosed with lung cancer. However, 7 months earlier, that mass was seen on a pre-operative chest x-ray.

The urologist who ordered the test failed to inform her father, and he was later sued, but was found not to be liable.

It’s a remarkable story, and a glaring error on the urologist’s part. An ordering physician always needs to take responsibility for the results of the test, even if it doesn’t fall under his specialty. His excuse was “that even though his signature was on the order form for the X-ray, he didn’t actually order it; the state of Massachusetts requires a pre-op chest X-ray for everyone over 50. Because he was mandated to order the X-ray, he couldn’t be held responsible; his name appeared on the form, but the state of Massachusetts had really been the one to order it.”

A ridiculous claim, and I can’t believe it worked in this instance.

In the end, the rules have now been changed, requiring the radiologist to directly talk to the ordering physician, who then must now track down the patient’s chart to follow-up on the results.

It’s sad that it had to take a malpractice trial to force some doctors to simply do their job.

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  • Anonymous

    The fact that this occurred at Harvard’s teaching hospital – Beth Israel – just illustrates how “conspiring” their lawyers can be.

    How could it be that no doctor(s) was (were) found guilty?

  • Anonymous

    A similar thing occurred with my mother except for we don’t have energy or desire to sue or even figure out if anybody is guilty especially without been sure it would’ve made any difference:

    My mother has stage 3A lung cancer. It was diagnosed by accident after she kept complaining of chest pain for months. She has coughed too, but this has been for a while and everyone thought it was the side effect of her blood pressure medication or/and allergies. A year before she had an episode of aetrial fibrillation. Ever since this incident she was losing weight and lost her appetite too.

    Since she was a) overweight with (treated) blood pressure and b) life long non-smoker in non-smoker family they obviously thought heart disease. Indeed she does have heart disease. One of her arteries was 90% blocked, so the doctors put a stent. When she still had chest pains the cardiologists thought it was something with her esophagus and ordered esophagram (or whatever it is called) and by accident discovered a nodule in her lung. Then CT scan showed enlarged lymph nodes in mediastinal area. Turned out stage 3A lung cancer, so she is now undergoing chemo.

    The interesting thing was that during her previous stay in the hospital when she had aetrial fibrillation as well as during the next stay when they put a stent, they took a number of heart x-rays and scans, so I guess they just didn’t pay attention to the lungs. At least the oncologist wondered about it – he was the one that first mentioned it and ask – when they did the stent, surely they had X-rays? He seemed upset about it and a bit angry.

    Oh well. I wonder if there is a bit of a danger when doctors assume that all chest pain in obese person is from heart disease or that a lifelong non-smoker with non-smoking husband and family cannot get lung cancer.

  • Anonymous

    Anon 4:35:
    It is more likely that the other X-rays (I’m assuming they were plain films) or the fluoroscopy used during the heart cath (when the stent went in) would NOT have picked up the lung cancer. Especially if it was a “nodule” which is by definition smaller than a “mass”. I’m sorry for your mother’s diagnosis, but it doesn’t seem that there was any way it should have been picked up earlier. This is THE biggest problem with lung cancer – there are no good screening methods and by the time it is diagnosed, it is late stage. Also like ovarian cancer. But anger is natural I suppose, and the doctors are the easiest to blame.

  • Anonymous

    Anon at 12:27 – thanks for the info. Actually I don’t feel anger because I do understand that early detection in case of lung cancer hasn’t been shown to do any good – this is why I mention not being sure it’d have made a difference.

    But your explanation makes me feel better, actually. Wondering “what if”, dwelling on the past and trying to assign blame makes one pretty miserable, IMHO.

  • Anonymous

    So what if the ordering physician never received the radiology report? As a physician in a “paperless” institution, I have ordered films only to have someone else’s name end up on the report.

    I’m sure there were plenty of “mis-routed” reports back in the paper days.