So much wrong here, it’s hard to know where to start

FOTB Brad Flansbaum sent me this piece. It’s about a former Congressman who is suing his Congressional doctors for malpractice. The piece is short, but here’s what you need to know:

According to the court filing, in early 2012, LaTourette, then still a congressman, went to George Washington University Hospital for an MRI after stomach pain and a diagnosis of mild pancreatitis.

The MRI revealed a 1.5-centimeter lesion on his pancreas. The doctor recommended follow-up imaging in six months. As a congressman, LaTourette’s doctor was at the Office of the Attending Physician at the Capitol.

According to the filing, the hospital doctor told a Capitol doctor about the imaging the day it was taken and sent a report to the Capitol doctor’s office the following day.

The Capitol doctors never performed the follow-up screening six months later, the filing says, and LaTourette himself had not been informed of the need for a follow-up.

It was not until last year, after his retirement in 2013, that he felt abdominal pain once again and doctors at the Cleveland Clinic discovered that he had developed a cancerous mass on his pancreas.

I have no idea who is at “fault” here. There’s certainly plenty of potential blame to go around. But how many system failures do you need. Here’s what I can see off the top of my head:

  1. Was there a proper discussion of the differential diagnosis before or after the MRI?
  2. Why were they getting the MRI for stomach pain and mild pancreatitis?
  3. Was the initial lesion even what developed into the cancer? Or was it an incidentaloma?
  4. When they “told” the Capitol doctor about it, what information was passed?
  5. When they “sent” the records, were they electronic or paper? (I bet the latter!)
  6. Were the data in the form of a document, or in the form of actual data that could be used?
  7. Was there a flag to get the docs to remember to do the follow-up test?
  8. Even if there was, why didn’t the patient himself follow up? He had a mass on his pancreas!
  9. Was he really not informed of the need for follow-up? Did he forget?

The MRI might have been overkill. There’s a complete lack of communication. The many different parts of the system couldn’t pass data efficiently. There were no systemic efforts to make sure that follow-up occurred. No clinical decision support. No effective use of the data. And this happened to a Congressman, at some pretty impressive facilities. You think regular people have it better?



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