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