Thursday, July 25, 2013

Follow-up on whose fault is it if a patient doesn't follow up

My post entitled "Who is at fault if a patient doesn't follow up?" from 7/19/13 has had over 1000 page views. There were several comments on Twitter.

In three parts, here is some follow-up on following up.

1. A surgeon saw a new patient with flank pain. He had undergone an appendectomy a few years before by another surgeon at a different hospital. He said that the surgeon told him the pathology report was "fine."

Physical examination was not enlightening.

A CT scan showed a possible ureteral stone. A urologist was consulted, saw the patient and said there was no stone.

The patient called the surgeon who told the patient to come back to her office to discuss further work-up. He did not keep the appointment. The surgeon made two more phone calls urging the patient to return and documented them in her office records. He was also called by the urologist, a consultant gastroenterologist and his family doctor. He never followed up with any physician.

Two years later he presented to the ED with a small bowel obstruction. At surgery, carcinomatosis from his ruptured mucinous carcinoma of the appendix was found.

The CT scan showing the possible stone was re-reviewed and still showed no evidence of a tumor.

The original pathology report said "mucinous tumor [not cancer] of the appendix."

Everyone except the surgeon who had done the appendectomy and the pathologist was sued. They escaped because of the statute of limitations.

The insurance companies advised all of the doctors to settle, which they did.

So much for documenting your attempts to have the patient seen.

2. Two of my Twitter followers from Australia sent me a link to a case that illustrates that patients in that country are somewhat responsible for their fate.

Briefly, it concerned a man who needed a Q fever vaccination for work. A skin test for Q fever was negative, but serology was weakly positive. An infectious disease specialist recommended that vaccination not be done. He was told to return in a month for a repeat serology. He failed to do so and contracted Q fever about 4 years later.

He sued. A judge ruled in favor of the physician saying the patient "understood the advice he was given by [the doctor] that he was low positive, that he needed further testing and that he could not be immunized. There was nothing in [the patient's] presentation in court or within his evidence that suggested he did not comprehend what was said to him by [the doctor]. He denied being told to return by [the doctor]. I reject his account for the reasons already mentioned."

3. This last one is hard to believe.

A brief "Viewpoint" article in JAMA from May of 2013 tells of the discovery of a new disease. It is called "Medication Nonadherence" and it has six different phenotypes.

They are as follows: "(1) the patient does not understand the relevance of medication adherence to continued health and wellbeing; (2) the patient has concluded the benefits of taking medications do not outweigh the costs; (3) the complexity of medication management exceeds the information processing capacity of the patient; (4) the patient is not sufficiently vigilant; (5) the patient holds inaccurate, irrational, or conflicting normative beliefs about medications; and (6) the patient does not perceive medication to have therapeutic efficacy."

I had trouble getting past the above portion of the paper.

However, the authors advocate screening all patients for this malady and treating it when found. They say, "Each medication nonadherence phenotype requires different diagnostic tools and treatments in the same way that subtypes of a medical condition, such as heart failure (diastolic vs systolic), require them."

I thank God I am no longer in practice.


surgeon s. said...

The surgeon who did the original appendectomy is the one who deserved to be sued! He should have known that path report wasn't "fine"

artiger said...

Scalpel, do you know in which state the first case occurred? Assuming, of course, that it occurred in the U.S., but where else would such happen?

Libby said...

It seems that any old thing is being classified as a disease. I would classify those as behaviours. They also sound like stuff therapists (SLP, OT, PT, Psych) say about preschoolers with developmental delays in their assessments.

Interesting how leading the wording is, making conventional medical establishment as the keeper of all health knowledge and any thoughts contrary to it is absolutely wrong. It also is relieving the patient of personal responsibility... "it's a disease, I can't help myself". I just shake my head, roll my eyes and wonder when homicide will be justifiable in some client relationships. (just kidding! "do no harm").

Anonymous said...


As mentioned in the previous post, the insurance companies have an obvious incentive to advocate 16 points of documentation regarding patient follow up. It costs them money. The answer from the perspective of a med-mal insurance company is likely to advocate documentation in an EMR to allow them to win cases in court rather than settle.

Furthermore, we won't know the extent to which the law would decide favorably in the named physicians' cases, since it was settled out of court.

We need malpractice reform. Sixteen documentation points isn't the answer and neither is settling out of court on a trumped up lawsuit (how on earth does the urologist have anything to do with a mucinous carcinoma of the appendix some pathologist missed years ago?).

As for the JAMA article - its adorable. In that little kid, pretend world kind of way. It would be lovely if we all rode unicorns in rainbow fields eating ice cream screening all patients for the 6 phenotypes of noncompliance in addition to diagnosing and treating disease.

But as it turns out, this is the real world, and not every patient can be screened for noncompliance... Obviously, we struggle to even get patients to follow up for serious complaints.

To be sure, noncompliance is a serious issue and frequently complicates care. However, every academician in print recommends every physician pursue further study... have a high index of suspicion... adhere to guidelines... I wager that the lust for publication gets the better of their practical sensibilities.

The question I have is how many patients per day, week, and year do the JAMA authors see, and how many get screened for noncompliance?

Skeptical Scalpel said...

Surgeon S, I agree with you, but the statute of limitations was interpreted as having expired. He could not be named in the suit.

Artiger, I do know the state but I would rather not disclose that to protect the surgeon involved.

Libby, I agree. Everything is a disease--obesity, sex addiction etc.

Anon, you are correct that the case I cited did not go to trial. It would have been interesting to see if the surgeon's documentation of attempts to have the patient return might have swayed a jury. Honestly, I doubt it.

I agree that screening everyone for nonadherence (noncompliance is no longer politically correct, see be impossible. And yes, many ivory tower docs spend their time thinking up things for other docs to do.

artiger said...

Scalpel, understood. Something tells me it happened in an physician-unfriendly state. I'd have fought it in my own state, unless there is more to the story than we know.

Anonymous said...

The problem isn't whether we 'screen' for medication non-compliance (we don't have time) it's the treatment of a choice as a disease. Pretty soon we will be handing out disability for intractable chronic lassitude syndrome. Patient accountability is apparently dead.

Anonymous said...

Hmmm where do we draw the line? I have had problems with some drugs given me by a doc. These were side effects listed in the handouts. I didn't blame the doc, just said that I had X side effects, is there anything else we can try? The nurse got upset with me and said well you have problems with everything.

So am I non compliant? Yes. Is there a reason for it? Yes.

Did the patient get blamed for something they had no control over? Yes. Did the doc get blamed? No.

How about some give and take? I'm one of the VERY few who does ask questions, I'm not sue happy, I'm educated. While I know the patients you all allude to here are plentiful, could we please make a few exceptions to the herd?


Skeptical Scalpel said...

First anon, I agree that making time to screen everyone for nonadherence is impossible.

Second anon, your anecdote involved a rebuke by a nurse, not a doctor. Are some doctors rude and dismissive of questions? Yes, indeed. Is that OK? No.

I do not defend those docs or condone that behavior. The point of this post is that doctors cannot be held responsible for everything that happens to a patient. Some people just don't act responsibly. They shouldn't be rewarded for that.

Libby said...

Second Anon: you weren't being non-compliant, you WANTED to follow the/a treatment course and it appears that you attempted to speak to the prescribing doctor about the side effects you were having. That is different from a patient being told to take a med or do whatever the treatment plan is (including follow-up appointments/exams) and the patient doesn't adhere to it or does so sporadically that he/she doesn't get better (or dies).

Oh, and tell the doctor about the nurse's behaviour. Zero tolerance for abuse goes both ways.

DD said...

We all realize that patient noncompliance is not new. we all know the reasons are many; disease and therapy-related factors, and of course the socio-economic and educational background of the pt. So, if a patient is cognitively unable to make optimal health related choices, we need to offer realistic, simple options that hopefully, result in some benefit to the patient and. . . compliance. But, finding out what works for each individual patient takes provider effort and time. Maybe documenting this time using "Medication Nonadherence" phenotypes, allows a higher code at an office visit. Should providers be reimbursed for dealing with complicated patients who need extra education and a simplified, tailor-made plan? Yes.

Skeptical Scalpel said...

Libby, good advice. Mention the nurse's behavior to the doctor.

DD, good point but I fear what would happen is "upcoding." That is, everyone would be a complex, noncompliant (nonadherent?) patient.


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