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.