Near-miss with NP - what would you do?

[pd1112]

A little over a year ago my S/O noticed a small ~ 1cm red lesion on her upper chest below her neck line. Over the next 6-7 months it started to concern me when it began scaling and the irregular borders began to heap up. To me, it looked almost identical to some of the pictures of BCC I had seen in texts, so I started to urge her to have someone look at it, but at the same time I told myself just to chill - we're in our 20s, so no way it's BCC (right..?) and I figured I just had med student syndrome ("must be either diabetes, cancer, or a rare genetic d/o"). About four months ago, she called her OB/GYN (no PCP at the time) who got her in to see a primary care NP within the same office. When she saw the NP & explained that she had had the lesion for about 9 months and was becoming concerned, mostly because of my repeated requests to have her get it looked at, she was told it was nothing to worry about and to put neosporin or OTC topical steroid on it for a week. When she came home and told me what she had been instructed to do, we laughed at the time/money spent for this "diagnosis" but decided to give it a try anyway. After that didn't work, about a month ago she got around to finding an internist who was accepting new patients. She agreed that it was definitely "something" and it "doesn't look bad, but doesn't look good either" and offered to do a simple excision in the office. It healed ok and she has a small resolving scar.

Today she got a call from the internist's office and was told that the pathology report had come back and it actually was basal cell carcinoma, and that she should return soon or get a referral to plastics or derm to have wider margins taken because the malignant cells extended to the borders of the initial excision. Needless to say, we are both shocked and concerned. Even though it's just a BCC, it's still not easy hearing you or someone close to you has cancer at age 25.

In regards to the title/point of this thread, we are wondering what to do about the initial "diagnosis" from the NP at the other practice. We are both in healthcare so we have no desire to seek any legal action even if this would be cause for a malpractice case (not sure if it technically does/doesn't, haven't analyzed it much because as stated, no interest in pursuing it anyway). That being said, we definitely think the NP and/or whoever is "responsible" for her should be informed of this outcome in some way, but neither of us (thankfully) have previous experience with anything like this and aren't sure about what would be an appropriate tactful way to do so. I'm not here to bash NPs. Justifiably or not, they have a somewhat prominent place in healthcare today and, as it appears, will only become more prominent in the near future. However, this is just one of the many unfortunate anecdotes involving NPs that many have shared on this site in recent months, and it seems that in most cases the errors/near-misses haven't been dealt with appropriately or even addressed at all.

Any thoughts on this situation?

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[acapnial]

A little over a year ago my S/O noticed a small ~ 1cm red lesion on her upper chest below her neck line. Over the next 6-7 months it started to concern me when it began scaling and the irregular borders began to heap up. To me, it looked almost identical to some of the pictures of BCC I had seen in texts, so I started to urge her to have someone look at it, but at the same time I told myself just to chill - we're in our 20s, so no way it's BCC (right..?) and I figured I just had med student syndrome ("must be either diabetes, cancer, or a rare genetic d/o"). About four months ago, she called her OB/GYN (no PCP at the time) who got her in to see a primary care NP within the same office. When she saw the NP & explained that she had had the lesion for about 9 months and was becoming concerned, mostly because of my repeated requests to have her get it looked at, she was told it was nothing to worry about and to put neosporin or OTC topical steroid on it for a week. When she came home and told me what she had been instructed to do, we laughed at the time/money spent for this "diagnosis" but decided to give it a try anyway. After that didn't work, about a month ago she got around to finding an internist who was accepting new patients. She agreed that it was definitely "something" and it "doesn't look bad, but doesn't look good either" and offered to do a simple excision in the office. It healed ok and she has a small resolving scar.

Today she got a call from the internist's office and was told that the pathology report had come back and it actually was basal cell carcinoma, and that she should return soon or get a referral to plastics or derm to have wider margins taken because the malignant cells extended to the borders of the initial excision. Needless to say, we are both shocked and concerned. Even though it's just a BCC, it's still not easy hearing you or someone close to you has cancer at age 25.

In regards to the title/point of this thread, we are wondering what to do about the initial "diagnosis" from the NP at the other practice. We are both in healthcare so we have no desire to seek any legal action even if this would be cause for a malpractice case (not sure if it technically does/doesn't, haven't analyzed it much because as stated, no interest in pursuing it anyway). That being said, we definitely think the NP and/or whoever is "responsible" for her should be informed of this outcome in some way, but neither of us (thankfully) have previous experience with anything like this and aren't sure about what would be an appropriate tactful way to do so. I'm not here to bash NPs. Justifiably or not, they have a somewhat prominent place in healthcare today and, as it appears, will only become more prominent in the near future. However, this is just one of the many unfortunate anecdotes involving NPs that many have shared on this site in recent months, and it seems that in most cases the errors/near-misses haven't been dealt with appropriately or even addressed at all.

Any thoughts on this situation?

I don't think that malpractice occurred since there wasn't any adverse outcome due to the missed diagnosis.

 

[cbrons]

Any thoughts? Yes. I had an attending tell me 2 weeks ago of a similar story where an NP missed a massive melanoma on the breast of one of his female patients (which he thankfully discovered a few weeks later).

Had a "neurology" NP near us miss a GB diagnosis in someone 2 weeks post diarrheal illness with symmetrical ascending paralysis. Had an NP a few months ago treating a patient for atrial fibrillation who essentially asked me if metoprolol was the same as warfarin. Had an NP three weeks ago diagnose iron deficiency anemia in someone with a ferritin of over 1,000.

These are just my personal experiences with NPs in a very very short period of time in the clinics. Needless to say I am not very confident at all whatsoever in their education or training so I would never allow a family member to see one for their health care and perhaps in your cases you should avoid that in the future as well.

Perhaps you can call her "supervising physician" (lol) and tell him what she missed. I mean, it might not have been obvious BCC to even an internist (or maybe it was) but at the very least I assume it should have been sent away for pathology.

The problem with NPs/PAs is that they rely on heuristics and protocol memorization so they are very prone to overestimate their own knowledgebase and misdiagnose rare conditions with benign run-of-the-mill ones. One of the benefits of medical school is that you come to realize how much information and stuff there is to know out there, and actually get legitimately scared that you will probably kill someone because you don't know the libraries worth of information out there.

 

[pd1112]

I don't think that malpractice occurred since there wasn't any adverse outcome due to the missed diagnosis.

Like I said, not the concern and no desire to even discuss.

I was hoping to get some thoughts on if/how to inform the NP/supervising physician, and more generally, what we can do as physicians to improve the education/training/practice of mid-levels since many/most of us will be working alongside and/or supervising them whether we want to or not.

 

[Doctor4Life1769]

The "supervising physician" isn't really supervising. FYI....

 

[frosted_flake]

Any thoughts? Yes. I had an attending tell me 2 weeks ago of a similar story where an NP missed a massive melanoma on the breast of one of his female patients (which he thankfully discovered a few weeks later).

Had a "neurology" NP near us miss a GB diagnosis in someone 2 weeks post diarrheal illness with symmetrical ascending paralysis. Had an NP a few months ago treating a patient for atrial fibrillation who essentially asked me if metoprolol was the same as warfarin. Had an NP three weeks ago diagnose iron deficiency anemia in someone with a ferritin of over 1,000.

These are just my personal experiences with NPs in a very very short period of time in the clinics. Needless to say I am not very confident at all whatsoever in their education or training so I would never allow a family member to see one for their health care and perhaps in your cases you should avoid that in the future as well.

Perhaps you can call her "supervising physician" (lol) and tell him what she missed. I mean, it might not have been obvious BCC to even an internist (or maybe it was) but at the very least I assume it should have been sent away for pathology.

The problem with NPs/PAs is that they rely on heuristics and protocol memorization so they are very prone to overestimate their own knowledgebase and misdiagnose rare conditions with benign run-of-the-mill ones. One of the benefits of medical school is that you come to realize how much information and stuff there is to know out there, and actually get legitimately scared that you will probably kill someone because you don't know the libraries worth of information out there.

 

[bc65]

If you wanted to educate the provider who missed it, leaving a phone message would be fine. Specifically, tell them, " just thought you would want to know that the lesion you saw on xx date didn't get better, so we had it biopsied, and it was a basal cell. No problem, I just thought you would want to know".

However, your assumption that this misdiagnosis is related to their level of training is misplaced. I have seen hundreds of misdiagnosed skin cancers, all of them missed by physicians, and many of them misdiagnosed by dermatologists. Most of them were basal cells, but a few melanomas as well, including a melanoma that was missed in a close family member who had been reassured by two dermatologists (partners) that the pigmented lesion was nothing to worry about. I did not conclude that the physicians who missed all these lesions were poorly trained. Rather, I assumed that these lesions were atypical in appearance. Similarly, I would conclude that in your case the problem was not that the care provider was a NP, but rather that skin lesions are hard to diagnose. If you want a higher likelihood of a correct diagnosis in the future, go directly to a dermatologist, but clearly there are no guarantees there either.

The problem isn't that the NP was poorly trained, but rather that providers of all types, including physicians, make many mistakes every day. I can assure you that you will acquire your own share of missed diagnoses in the future. So, feel free to politely give follow up, but go easy, and be prepared to be on the receiving end of similar messages throughout your career. You will become more understanding of the mistakes of others as you gain more experience and make more mistakes of your own.

By the way, basal cell excisions are often deferred 2 or 3 months by patient request, so the delay in the excision in this case is nothing to be concerned about.

 

[pd1112]

@bc65 thanks for the reply, you're absolutely right about my assumption. I think I was just thrown off by the advice to use neosporin on something that had been there for 9 months and really had no signs of infection or inflammation. It seemed on the surface like the "put a bandaid on it"-type of condescending advice that you might give if you're annoyed with an over-worrisome patient who keeps calling/wanting to be seen for something new every week.

 

[bc65]

After reading the additional details in your last post, I think that you're correct in being annoyed with the advice you got. Neosporin is not going to do anything on a 9 month old lesion. Some education is in order. But there's a good lesson there. If you don't know what's causing a symptom, don't blow it off. Either figure out what it is, or refer them to someone else. Or put a time limit on it, e.g. I think you're having tension headaches, but if they are still there in 2 or 4 weeks, let me know, and we'll do some tests.

I still wouldn't attribute the bad advice to their training, just their style. Physicians are just as bad.

By the way, I never recommend neosporin. There are lots of rashes due to the neomycin in Neosporin; the rashes then get confused with cellulitis. I prefer bacitracin. Others use Aquaphor.

 

[ACSurgeon]

If you wanted to educate the provider who missed it, leaving a phone message would be fine. Specifically, tell them, " just thought you would want to know that the lesion you saw on xx date didn't get better, so we had it biopsied, and it was a basal cell. No problem, I just thought you would want to know".

However, your assumption that this misdiagnosis is related to their level of training is misplaced. I have seen hundreds of misdiagnosed skin cancers, all of them missed by physicians, and many of them misdiagnosed by dermatologists. Most of them were basal cells, but a few melanomas as well, including a melanoma that was missed in a close family member who had been reassured by two dermatologists (partners) that the pigmented lesion was nothing to worry about. I did not conclude that the physicians who missed all these lesions were poorly trained. Rather, I assumed that these lesions were atypical in appearance. Similarly, I would conclude that in your case the problem was not that the care provider was a NP, but rather that skin lesions are hard to diagnose. If you want a higher likelihood of a correct diagnosis in the future, go directly to a dermatologist, but clearly there are no guarantees there either.

The problem isn't that the NP was poorly trained, but rather that providers of all types, including physicians, make many mistakes every day. I can assure you that you will acquire your own share of missed diagnoses in the future. So, feel free to politely give follow up, but go easy, and be prepared to be on the receiving end of similar messages throughout your career. You will become more understanding of the mistakes of others as you gain more experience and make more mistakes of your own.

By the way, basal cell excisions are often deferred 2 or 3 months by patient request, so the delay in the excision in this case is nothing to be concerned about.

My thoughts exactly. Especially about the errors in diagnosis and management that we all inevitably make.

 

[TooMuchResearch]

I don't think that malpractice occurred since there wasn't any adverse outcome due to the missed diagnosis.

You don't know that.

This individual has a locally invasive cancer that spread beyond the border of a (probably) appropriate excision. It won't take that good of a derm expert witness to argue the revised widened excision and further spread of cancer could have been avoided with appropriate prompt diagnosis or referral by the NP.

 

[bc65]

This individual has a locally invasive cancer that spread beyond the border of a (probably) appropriate excision. It won't take that good of a derm expert witness to argue the revised widened excision and further spread of cancer could have been avoided with appropriate prompt diagnosis or referral by the NP.

It would be very hard to make the case that the delay caused any appreciable harm to the patient. These lesions are extremely slow growing. It's common for patients to wait 3 months or more before having them excised. While theoretically the lesion might have grown an additional several millimeters in diameter in that time, it would be hard to argue that there was a significant cosmetic difference in an incision on the chest that's a few millimeters longer. The fact that it wasn't completely excised is related to the margin chosen by the person who did the excision, and not to the delay per se. Basal cell cancers tend to have irregular growth subcutaneously that frequently can't be determined by inspection alone. That's why there's an entire specialty of dermatology, Mohs, devoted to their excision in stages with microscopic evaluation of the entire excised margin. While anything is possible, I doubt that a malpractice attorney would take this case.

However, that's not to say that the practitioner wasn't wrong. But what was egregious was not misdiagnosing a lesion. Rather, it's their apparent failure to make any reasonable diagnosis at all, followed by inappropriate treatment ( since this apparently didn't look like an infection ) , and no plan for follow up and/ or referral. It's the lack of follow up and instructions to the patient as to what to do if there's no improvement that will often get you into trouble.

 

[samac]

I honestly think it doesn't matter if you inform them or not. Let's be real, the NP probably doesn't care that she misdiagnosed one BCC on a patient that she saw one time. If you called and left a message she probably wouldn't ever receive it.
I don't say this to be mean or insensitive, but I don't want you to get restless worrying about it.

 

[pd1112]

I honestly think it doesn't matter if you inform them or not. Let's be real, the NP probably doesn't care that she misdiagnosed one BCC on a patient that she saw one time. If you called and left a message she probably wouldn't ever receive it.
I don't say this to be mean or insensitive, but I don't want you to get restless worrying about it.

Interesting; why do you think she wouldn't care? IMO most providers would want to know.

 

[samac]

Interesting; why do you think she wouldn't care? IMO most providers would want to know.

I just really think she wouldn't. You all aren't regular patients of hers and it was one visit a while back. Very likely she doesn't remember you all and you didn't follow up after a week.
What she was doing was following a protocol, trying the easiest way out first and if it still persisted after a week then you return and move on and take the next step.

 

[pd1112]

I just really think she wouldn't. You all aren't regular patients of hers and it was one visit a while back. Very likely she doesn't remember you all and you didn't follow up after a week.
What she was doing was following a protocol, trying the easiest way out first and if it still persisted after a week then you return and move on and take the next step.

You're probably right about not remembering my s/o specifically as a one-time patient nor any specifics about the lesion after examining it for 20 seconds. I don't think any protocol applied in this case nor do I think there's any protocol that says use OTC topicals for chronic lesions. Likewise, there was no plan or instructions for followup. But the point is, missing a cancer dx is missing a cancer dx, no matter the severity. Even with both of us knowing that a BCC isn't that serious in the grand scheme, it's still unsettling to be told you have cancer at the age of 25; even more so for the vast majority of patients with no medical background, who would be more likely to stir up some backlash towards the provider (confrontation, social media, legal action even if not warranted). I hope that we all want to be informed of our mistakes and oversights so we can minimize them in the future. By reaching out to her, we aren't hoping for a "got you" moment, apology or anything similar, although that might be appropriate for other patients in order to minimize the chance of any backlash. The hope would be that because she was informed, the next time she has an unfamiliar case, she might take a little time to consider a more thorough differential or consult her attending, if neither were done in the first place.

 

[Psai]

Despite all the dislike I have for NPs, I think that a missed diagnosis is not the issue either. Anyone can miss a diagnosis. Medicine is difficult and when you hit the clinical years, you will see that diseases rarely fit the textbook definition. A lot of the time, we go with our best guess of what's going on based on the available information and hope for the best. You also have a misguided view of what attendings actually do with midlevels. There is little supervision unless the midlevel decides that the disease is serious enough to warrant the doctor's attention. However, doctors are much better trained than midlevels to determine what is serious or not so you see the dilemma here.

It's also tough to get good followup because if you make a mistake, the person is likely to go to someone else in the future

 

[Bacchus]

You're probably right about not remembering my s/o specifically as a one-time patient nor any specifics about the lesion after examining it for 20 seconds. I don't think any protocol applied in this case nor do I think there's any protocol that says use OTC topicals for chronic lesions. Likewise, there was no plan or instructions for followup. But the point is, missing a cancer dx is missing a cancer dx, no matter the severity. Even with both of us knowing that a BCC isn't that serious in the grand scheme, it's still unsettling to be told you have cancer at the age of 25; even more so for the vast majority of patients with no medical background, who would be more likely to stir up some backlash towards the provider (confrontation, social media, legal action even if not warranted). I hope that we all want to be informed of our mistakes and oversights so we can minimize them in the future. By reaching out to her, we aren't hoping for a "got you" moment, apology or anything similar, although that might be appropriate for other patients in order to minimize the chance of any backlash. The hope would be that because she was informed, the next time she has an unfamiliar case, she might take a little time to consider a more thorough differential or consult her attending, if neither were done in the first place.

Its very hard to unbiasedly evaluate all these statements as we don't know the NP's side of the story. Things get missed. Be glad this wasn't a LBP written off as muscle strain which actually was osteo mets or RLQ pain thought to be colitis but was an active appendicitis or... etc. If I see lesions in the office I routinely tell patients to try lotions, OTC steroids or may prescribe something. Unless you have a fungating, ulcerating or melanotic mass I will usually monitor it. I explicitly tell my patients to come back in a certain period of time to CYA and put it in their clinical summary as well so I'm protected. But ultimately, it is the patient's responsibility to schedule follow up. No one is going to bar you from returning to the office.

 

[pd1112]

Despite all the dislike I have for NPs, I think that a missed diagnosis is not the issue either. Anyone can miss a diagnosis. Medicine is difficult and when you hit the clinical years, you will see that diseases rarely fit the textbook definition. A lot of the time, we go with our best guess of what's going on based on the available information and hope for the best. You also have a misguided view of what attendings actually do with midlevels. There is little supervision unless the midlevel decides that the disease is serious enough to warrant the doctor's attention. However, doctors are much better trained than midlevels to determine what is serious or not so you see the dilemma here.

It's also tough to get good followup because if you make a mistake, the person is likely to go to someone else in the future

Its very hard to unbiasedly evaluate all these statements as we don't know the NP's side of the story. Things get missed. Be glad this wasn't a LBP written off as muscle strain which actually was osteo mets or RLQ pain thought to be colitis but was an active appendicitis or... etc. If I see lesions in the office I routinely tell patients to try lotions, OTC steroids or may prescribe something. Unless you have a fungating, ulcerating or melanotic mass I will usually monitor it. I explicitly tell my patients to come back in a certain period of time to CYA and put it in their clinical summary as well so I'm protected. But ultimately, it is the patient's responsibility to schedule follow up. No one is going to bar you from returning to the office.

I think my intentions are being misunderstood. I'm in my clinical years and I've worked with midlevels in different practice settings for over 2 years (3 months of IM & 2 years in an ED & wards before med school), so I have a good understanding of the variety of their work relationships with attendings. I know diseases don't present like the texts read. I know things gets missed every day. I know it's the patient's responsibility to followup. She didn't originally in this case because she essentially felt that her concern wasn't taken seriously in the less than two minute visit, and she wanted to establish care with an FP/internist to manage her other conditions anyway. The NP was just whom she could see sooner vs. later as she hadn't found a PCP in this area yet and the NP was linked to the primary care part of her ob/gyn's office. I don't have an issue with this. I wasn't there when it happened. I have no ill-feelings towards the NP.

I started this thread to see what others would do in my s/o's situation in regards to letting the NP know about the outcome, i.e. when you miss something which you may or may not have been confident managing in the first place, how do you want to be informed - phone call, letter, in-person, not at all? She's still going to be in that office at least annually to see her ob/gyn & she has no desire to make it confrontational/awkward/unprofessional anyway. Likewise, when you have a midlevel working under you & independently seeing cases of which he/she is "comfortable", how do you want to be informed when he/she misses something - phone call, letter, in-person, not at all? We both thought it'd be appropriate to do so & would want to know if it was either of us, but have no experience with anything like this. We aren't thinking, "Oh lawd, we can't screw this up because it could change the NPs career forever." We just want to learn since we'll undoubtedly be on the other side of this at some point in our careers, and I enjoy & respect the thoughts & opinions of most members of this site, so I thought I'd reach out.

 

[bc65]

Sorry that I misunderstood your question.

The friendliest way to give the follow up is to leave them a message by phone. The most hostile way to deal with this would be a letter to the head of the practice, department, medical group, or hospital, as applicable. The middle ground would be a phone call to the immediate supervisor.

Here's what I would say if I wanted to give them follow up and not hurt their feelings. I would call, and try to adopt a tone of happy amazement, as in, " Hey, I have some follow up that you might be interested in. Do you remember that 23 yo patient that you saw who had a lesion on her chest, kind of flaky and scaly that had been there for 9 months? Guess what it turned out to be! I was really surprised to find this in a 23 yo, but despite her young age it turned out to be a basal cell ca! Fortunately, she went to her PCP to have it looked at again and they biopsied it. Pretty interesting, isn't it. I thought you might be interested."

If you were angry and wanted them to know it, you would write a letter in which you describe what happened, and indicate that the NP didn't take the patient's concern seriously, prescribed treatment guaranteed to be useless, and never made plans for f/u. or referral, and obviously the NP didn't have a clue. You suggest some basic education and protocols for the NP and for the practice. You state that you are very disappointed and thought they should know what's going on in their practice / hospital.

The middle ground would be to talk to the head of the practice and say, " I thought you should know what happened to us. We're not angry, but as a fellow medical professional I thought you would want to know what your staff member did. This could have been bad. Maybe you should talk to the practitioner and make sure that they arrange for f/u if the problem a patient came to see you about doesn't get better.

Similarly, for a missed appendicitis, the nice way: " Hey, remember that kid you saw yesterday with abdominal pain and gastroenteritis? Guess what, they came back the next day with worsening pain, and we did a white count and it was 16,000 with a shift, and CT scan showed appendicitis! I guess they weren't guarding when you saw him, but it turned out to be a ruptured appendix. Too bad they didn't come back in sooner. Well, I guess that early presentation was misleading."
The honest/mean way: " That kid you saw yesterday had obvious appendicitis. He had mid abdominal pain that moved to the RLQ. You never did a WBC, and there's no mention of your abdominal exam in the chart. What were you thinking? "

Now, for your SO: Patients with one basal cell usually get more, so they should get seen by derm for a check at least once a year. Next, sun avoidance. Your SO needs to start staying out of the sun, use lots of really good sunscreen, wear long sleeves even in the summer, and stay away from the beach. No more tans. Most important, wear hats with big brims. At my hospital, you can spot the Mohs dermatologists from across the parking lot because they are the ones wearing the big hats. I work with those guys a lot, and I wear big hats too. I'm male, but I buy women's sun hats because they have bigger brims. I have hats with brims from 4" out to 6 1/2", which I wear just to walk from my car to the parking lot, or if I go out to get the mail. I attract a bit of attention wearing those big hats, but not as much as patients do after they have stage 1 of a forehead flap nasal reconstruction. ( google that if you haven't seen it ). See the adventure hat on Sundayafternoons.com, ( Costco sometimes has cheaper knockoffs ) and the big beach hats on sunprecautions.com and coolibar.com. Sunprecautions hats are the biggest I've found, short of the big 9 inch "derby hats" , which are impractical to wear. Staying out of the sun will not only help prevent skin cancers, but it will keep you looking young and prevent wrinkles. You may not care about that now, but you will in 10 years or so.

 

[princekc]

The problem with NPs/PAs is that they rely on heuristics and protocol memorization so they are very prone to overestimate their own knowledgebase and misdiagnose rare conditions with benign run-of-the-mill ones.

The statement above only applies to NP not PA. It's interesting to see how many do not understand the difference in training of an NP and PA.