Legally Speaking

LEGALLY SPEAKING
Risk management in obstetrics and gynecology

Failure to evaluate a persistent breast mass

In January 2001, a 41-year-old California woman presented to her family practice physician complaining of a lump in her left breast. No abnormality was found on ultrasound, but the report ruled out a cyst and advised further evaluation if clinical findings warranted. The patient was not referred to a specialist and at her next appointment, was assured by the physician that the lump was benign; no further examination of her breast was done.

When the woman returned for her annual exam in May 2001, the lump was found to be 5 x 5 cm, and the breast was indurated. The physician noted these findings in the record, continued to prescribe oral contraceptives, and did not refer the patient for evaluation of the mass. During the woman's next two appointments, the physician performed sigmoidoscopy and a treadmill test, but made no notes about the breast mass and did not examine the breast. Two months later, the patient presented to him with a red, inflamed breast with nipple inversion, which he diagnosed as acute contact dermatitis and treated as such at two subsequent appointments. When the patient finally insisted on a referral, the physician agreed to the request and referred her to a specialist. In October 2001, the woman was seen by a surgeon and was diagnosed with stage IV breast cancer with liver metastasis.

The patient sued the physician, claiming that he should have referred the patient to a breast surgeon in May 2001, when the mass was found to be 5 x 5 cm. At deposition, the physician testified that when he charted these findings, his differential diagnosis acknowledged that malignancy was most likely. His further claim that he referred the woman to a surgeon at that time was inconsistent with his actions in all subsequent encounters with the patient. No discussions with the patient in May 2001 about seeing a surgeon were noted in the chart nor was an earlier request for referral documented but there were notes from several appointments at which the physician apparently did not mention or even examine the woman's breast. This case was settled after a half day of mediation for $500,000.

Legal perspective