medical legal dilemma

[CoolWhipp]

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Hi everyone, I’ve been mulling over something and wanted to get your take on it. I’m curious about medico-legal cases involving emergency physicians ordering CTs—specifically when incidental findings pop up that aren’t related to the reason for the visit. Say a patient comes in with chest pain, gets a CT, and it rules out anything acute, but there’s an incidentaloma—like a small lung nodule or an adrenal mass—that doesn’t get discussed with them. Months or years later, that finding turns out to be the root of serious morbidity or even death. Based on medmalreviewer the physician seems to lose this case. Are EPs held liable for not addressing every incidental finding?

On the flip side, do you think it’s realistic—or even necessary—for physicians to go over every single thing on a CT with the patient in the ED? Time’s tight, and the focus is usually on the acute issue. Plus, with systems like MyChart, patients can see their full reports now. Does that shift the responsibility at all, or is it still on us to flag everything verbally? What about a home print out of their entire results, what if I don't go over every single part of the CT with them verbally?

 

[Dr Mantis Toboggan]

Hi everyone, I’ve been mulling over something and wanted to get your take on it. I’m curious about medico-legal cases involving emergency physicians ordering CTs—specifically when incidental findings pop up that aren’t related to the reason for the visit. Say a patient comes in with chest pain, gets a CT, and it rules out anything acute, but there’s an incidentaloma—like a small lung nodule or an adrenal mass—that doesn’t get discussed with them. Months or years later, that finding turns out to be the root of serious morbidity or even death. Based on medmalreviewer the physician seems to lose this case. Are EPs held liable for not addressing every incidental finding?

On the flip side, do you think it’s realistic—or even necessary—for physicians to go over every single thing on a CT with the patient in the ED? Time’s tight, and the focus is usually on the acute issue. Plus, with systems like MyChart, patients can see their full reports now. Does that shift the responsibility at all, or is it still on us to flag everything verbally? What about a home print out of their entire results, what if I don't go over every single part of the CT with them verbally?

It’s tough but you have to tell these people about anything that may end up being cancer IMO. I usually say something like don’t lose sleep over this but occasionally we find a “baby cancer” (yes I use this term) this way. So you need XYZ rescanned in 3-6 months. And I type into their chart and circle it on the print out. Maybe I’m OCD.

 

[Jball43]

Based on the literature, one commonly referenced case is Davy v. Schiffer (2008, New York). In that case, a CT scan ordered to evaluate for pulmonary embolism revealed a spiculated lung nodule that was suggestive of cancer. The failure to communicate this incidental finding to the patient led to a claim where summary judgment was denied on that issue, meaning there was enough evidence to raise questions about negligence. I don’t think anyone knows what happened to the MD though. I suspect a confidential settlement was reached.

If you want a thorough read on it here is a link and a break down of cases not just EM.

If you want my personal thoughts, I think situations like this is what malpractice insurance is for 😅

 

[hoot504]

Anyone I am discharging, absolutely they are notified of incidentalomas (and the conversation is documented in my note). What's tougher are the ones that are admitted. Often times I'm assuming the inpatient team will deal with these findings, but maybe at my own medico-legal peril. Quite sure that's basically standard practice, however. Curious to hear others chime in.

 

[ERMudPhud]

I try to discuss every incidentaloma and more importantly document on their discharge paperwork. "You have XYZ. You will need to discuss this with your primary care doctor and make sure it gets re-imaged in 3-6 months" Is that guaranteed to be enough? no. Does it let me sleep at night yes.

The bigger problem is the incidentalomas that get buried in the body of the read but not listed in the final list of findings. Easier to miss those. One of the tele-rad services also reads a CT C/A/P as a separate chest and abdomen so the final impressions for the chest are buried in the middle of a two page read with only the abdomen findings at the end. So you get "No acute intrabdominal pathology" at the end of the read with "Spiculated lung nodule" in separate chest impression buried in the middle of the two pages. Almost missed a few of those. I complained but they haven't fixed it.

Also, like hoot said. There is no good way for me to make sure the admitting team includes this stuff in the discharge instructions of admitted patients. Fortunately most of them seem more anal than me.

 

[doitalldoc]

Hi everyone, I’ve been mulling over something and wanted to get your take on it. I’m curious about medico-legal cases involving emergency physicians ordering CTs—specifically when incidental findings pop up that aren’t related to the reason for the visit. Say a patient comes in with chest pain, gets a CT, and it rules out anything acute, but there’s an incidentaloma—like a small lung nodule or an adrenal mass—that doesn’t get discussed with them. Months or years later, that finding turns out to be the root of serious morbidity or even death. Based on medmalreviewer the physician seems to lose this case. Are EPs held liable for not addressing every incidental finding?

On the flip side, do you think it’s realistic—or even necessary—for physicians to go over every single thing on a CT with the patient in the ED? Time’s tight, and the focus is usually on the acute issue. Plus, with systems like MyChart, patients can see their full reports now. Does that shift the responsibility at all, or is it still on us to flag everything verbally? What about a home print out of their entire results, what if I don't go over every single part of the CT with them verbally?

I was named in one lawsuit but I got dropped. It was the hospitalist's, PCP, and patient's fault for not addressing the incidentaloma. My notes very clearly noted that there was a concern for cancer. I also know of other EM docs that were named one those incidentalomas. You ordered the test, you need to address the findings in it. You need to document that you discussed with the patient and say in the discharge instructions that you talked to them about it and that they need to follow up to make sure it's not cancer.

 

[southerndoc]

I was sued for an incidental lung nodule in a patient I admitted to the hospitalist service.

Patient presented with slurred speech, facial droop, and I think extremity weakness (it's been a few years). CT head negative. Seen by stroke neurology who recommended TIA workup. Admitted to hospitalist. Our stroke protocol order set includes a baseline chest x-ray. I do not remember looking at the x-ray and did not document any findings. Radiologist read the x-ray 3 minutes after I signed my note (and after patient was upstairs on the floor). Noted a small pulmonary nodule and recommended follow-up CT.

Plaintiff's counsel said I should've ordered CT in the ER, not let the patient leave the ER until official read, etc. I distinctly remember telling him if I keep every patient in the ER until a formal read is made, then I can't let the trauma surgeon take a hypotensive splenic lac to the OR until their hand x-ray is read.

Thankfully I was dismissed after deposition. Of note, in this particular case, the hospitalist had the chest x-ray findings incorporated into their H&P and the follow-up physician (in another health system) also had the chest x-ray findings incorporated into her follow-up visit note 3 days after discharge from the hospital. Patient presented to PCP multiple times over a six month period with cough and weight loss. PCP never ordered a chest x-ray despite this 70+ year old female being a smoker. Patient developed lung cancer and died from it.

I now document every single incidental finding (nodule, coronary artery calcifications, etc.) and both tell the patient to follow up and document that I told them. I also add it as a diagnosis and add it to their problem list so that any physician in the health system sees it on the problem list during a follow-up visit.

 

[Porfirio]

I was sued for an incidental lung nodule in a patient I admitted to the hospitalist service.

Patient presented with slurred speech, facial droop, and I think extremity weakness (it's been a few years). CT head negative. Seen by stroke neurology who recommended TIA workup. Admitted to hospitalist. Our stroke protocol order set includes a baseline chest x-ray. I do not remember looking at the x-ray and did not document any findings. Radiologist read the x-ray 3 minutes after I signed my note (and after patient was upstairs on the floor). Noted a small pulmonary nodule and recommended follow-up CT.

Plaintiff's counsel said I should've ordered CT in the ER, not let the patient leave the ER until official read, etc. I distinctly remember telling him if I keep every patient in the ER until a formal read is made, then I can't let the trauma surgeon take a hypotensive splenic lac to the OR until their hand x-ray is read.

Thankfully I was dismissed after deposition. Of note, in this particular case, the hospitalist had the chest x-ray findings incorporated into their H&P and the follow-up physician (in another health system) also had the chest x-ray findings incorporated into her follow-up visit note 3 days after discharge from the hospital. Patient presented to PCP multiple times over a six month period with cough and weight loss. PCP never ordered a chest x-ray despite this 70+ year old female being a smoker. Patient developed lung cancer and died from it.

I now document every single incidental finding (nodule, coronary artery calcifications, etc.) and both tell the patient to follow up and document that I told them. I also add it as a diagnosis and add it to their problem list so that any physician in the health system sees it on the problem list during a follow-up visit.

This just demonstrates the extent of modern medicine burden we have. I have always wondered why doesn’t the Radiologist have the burden of telling and educating the patient on their (Radiologist’s) findings.

 

[AlmostAnMD]

It's not a "dilemma" in my state. At all. You are liable for every incidentaloma. We were told to add them to final dx as well (lung nodule, thyroid nodule, etc). If Ultrasound rec from CT for thyroid nodule was recommended we needed to give them that follow up too

Another reason I got out. The number of incidental findings is insane. I feel like everyone has a nodule...

 

[EctopicFetus]

I have a macro for this.. i also add some language to their DC papers.. IMO the risk comes from the resident / MLP charts I sign.

 

[RustedFox]

My macro reads:

"Care was taken to review the incidental findings (in this case: ________ ) with the patient and/or family at bedside, and the need for timely follow-up with the appropriate physician was emphasized. The patient was handed a copy of the results with relevant findings highlighted to facilitate ease of discussion at follow-up. Patient indicated understanding of these instructions in both word and in gesture."

I then add the incidentaloma to the diagnosis list at the end.

Then I'm done.

 

[CoolWhipp]

My macro reads:

"Care was taken to review the incidental findings (in this case: ________ ) with the patient and/or family at bedside, and the need for timely follow-up with the appropriate physician was emphasized. The patient was handed a copy of the results with relevant findings highlighted to facilitate ease of discussion at follow-up. Patient indicated understanding of these instructions in both word and in gesture."

I then add the incidentaloma to the diagnosis list at the end.

Then I'm done.

I'm taking this.

 

[Birdstrike]

Put a macro or template in your EMR like this and fill in the blanks:

“Patient was advised that while his CT scan shows no _____, it does show the presence of ______ for which he was told he needs to follow up with his primary care physician as soon as possible. The patient indicated understanding of the importance of follow up and was given a copy of the CT report to take to his PCP with whom he knows to follow up with for testing as indicated”

I once was saved by this documentation, when a patient failed to follow up on something that turned out to be a spinal cord tumor. Documentation was clear.

 

[TooMuchResearch]

Lung nodule on CT, advised pt and referred to lung nodule clinic (or primary care depending on where I'm working).

 

[thegenius]

Lung nodule on CT, advised pt and referred to lung nodule clinic (or primary care depending on where I'm working).

Lung Nodule Clinic?

What kind of fairy tale land do you work in?

 

[JacobMcCandles]

Lung Nodule Clinic?

What kind of fairy tale land do you work in?

It’s just right down the hall from the Adrenal Adenoma Clinic.

 

[TooMuchResearch]

Lung Nodule Clinic?

What kind of fairy tale land do you work in?

Not Kaiser.

I've always had nodule clinic access. Even in residency. It sounds nice but keep in mind it's just one more thing they want me, the EP, to do. Refer to nodule clinic, order the outpatient Echo, have the cardiac monitor applied before discharge, refer to every specialist, etc.

 

[ShockIndex]

One of the incidentalomas that is frequently missed is the head CT ordered for head trauma, headache, or some cause other than acute stroke that shows findings consistent with prior remote strokes that the patient is unaware of because they were clinically silent events. These patients are at much higher risk for an acute stroke in the next year and need to be informed of the findings and the need for further testing. I’m not saying that you should admit them for an expedited workup, but the finding needs to be noted and discussed. I recall hearing about a series of cases stemming from these findings on one of the medmal podcasts. Scary stuff.