Late Diagnosis of Colon Cancer

In this episode of the MagMutual podcast, Steve Adubato, PhD, speaks with Lisa Lefkovits, MD, about an actual case involving the late diagnosis of colon cancer in a patient that resulted in a medical malpractice claim. Dr. Lefkovits discusses some of the complicating factors in this case, including a noted difference between the patient’s experience and what was documented in the chart, and shares her thoughts on what could have been done to avoid the poor outcome. Dr. Lefkovits also provides insights on how ensure age- appropriate screenings, effective patient communication, thorough documentation and safe, quality medical care.

Release Date: 9/13/2023; Recorded Date: 4/27/2023

Podcast Transcript

ADUBATO:  Hi everyone. Welcome to the MagMutual Podcast. This is Steve Adubato. Now, for folks who have never listened to us before, this is a podcast dealing with a range of healthcare issues, topics and trends. Our goal is to ensure a safer practice environment for all physicians, and we’re joined today by Dr. Lisa Lefkovits, who is a board-certified internal medicine specialist at Laureate Medical Group in Metro Area Atlanta and a member of the medical faculty at MagMutual. Doctor, so good to have you with us.

LEFKOVITS:  Thank you so much. Glad to be here. 

ADUBATO:  Right out of the box, why don’t you describe your role at MagMutual.

LEFKOVITS:  At MagMutual, I’m one of the faculty reviewers, so I review cases. I read the cases of physicians who are involved in a complaint and review them, and I give a report to MagMutual and let them know what I think has gone on in the case and what things could be done in the future to prevent issues like this.

ADUBATO:  So, in that spirit, let’s try something a little different on the podcast today. Let’s go through an actual medical malpractice case that involves a physician insured by MagMutual. Give us a brief synopsis. You know the case. I have the same facts, but you interpret them differently because of your expertise. What are the basic facts, doctor, about this case, and then we’ll talk it through.

LEFKOVITS:  Sure. This is a female who was being taken care of by a primary care internist and she went to that physician between the ages of 50 and 54, and some years before that.  She went to this physician apparently for a routine visit in about 2016 when she was 52 and was advised to have a colonoscopy. That didn’t happen. Then, a couple years later, she continued to have some complaints of rectal bleeding. When finally she did get referred again for the colonoscopy, she did the colonoscopy and she was diagnosed with cancer. By that time, the cancer was advanced and metastasized.

ADUBATO:  So, it’s interesting here because the whole idea, the whole reason why we’re doing this is to talk through a case like this that involves a physician that is, in fact, insured by MagMutual. We then ask ourselves, “Okay, how do you deal with this”? So right out of the box, the discrepancy between the patient’s version of what happened and the physician’s documented notes, talk to us about that.

LEFKOVITS:  Yes, I was thinking about that a lot when I read through this case, because there is the science of medicine and the art of medicine, I always say.

ADUBATO:  Right.

LEFKOVITS:  So, the science of medicine, a lot of that includes documentation. So this physician documents that he discussed a colonoscopy with her at age 52. What that conversation was, we weren’t there, so the patient interpreted it as either it wasn’t necessary or she didn’t go. We’re not sure what the truth is. Those conversations are private conversations and what’s so hard about medicine in those circumstances is that’s the art of medicine. How do we convey to the patients the importance? How do we also build the patient’s trust and have them understand why we’re deciding or referring them to do certain tests - tests that maybe they don’t want to do. Maybe they don’t have symptoms at that time and they feel it’s not necessary, but we know it’s necessary. So what do those conversations look like? That’s what I’m really interested in. That’s what makes quality physicians and that’s what helps physicians to make sure the patients are getting the care they need and avoid lawsuits.

ADUBATO:  How important are those notes?

LEFKOVITS:  The notes are so important. Documentation is so important. When I was in training, I remember they used to say, “Remember, your notes need to be written so that if you never see that patient again, any doctor could come read your note and know exactly what they need to do for that patient.” Let’s say you move to Alaska. They need to know exactly what you were thinking. That’s where the notes are the science of medicine. Documentation is part of being a meticulous doctor and I am very interested in how doctors provide quality and how they are meticulous. I think that’s really important and I think that’s where some doctors get into trouble with their notes. They might think, “Oh, we had a great visit, we’re hugging, the patient really likes me.” They leave. The documentation may not be great and something happens. The documentation has to be very solid. I will write a paragraph about my conversation with the patient about why I recommend colon cancer screening and where they can go for colon cancer screening. I even document that I gave the referral in hand to the patient on this date because I want to make sure that it’s documented.

ADUBATO:  You know, as I’m listening to you, I’m a student of communication. I think about communication, miscommunication, people’s interpretation of communication or misinterpretation of communication, and I don’t want to get overly philosophical, but sometimes I think there are separate realities, which is a term that Dr. Richard Carlson talked about in his book, Don’t Sweat the Small Stuff. Separate realities, meaning there’s a reality of the patient, and we can’t really understand how that patient, how this woman who is a patient of this physician, we don’t know how she interpreted what was said to her. The physician has a “separate reality” — what specifically is in those notes and what that physician intended to communicate. But how the heck can we be confident that the notes as reflected in the reality of the physician is interpreted by the patient in the same way that the doctor intended? (Is there a question there?) 

LEFKOVITS:  That’s a very, very important topic to me in my practice. That’s the art of medicine. One of the ways that I practice with my patients is I try to develop that trusting relationship with that patient so we have very good communication. Communication is extremely important, and part of that is trust. Now, you have all kinds of patients. I have patients that I’m just like them, they’re just like me, we understand each other, and then I have patients that come from all walks of life that are not like my walk of life. Well, I have to communicate to that patient, too, and they communicate to me. So right when I start with a patient at the very beginning, which is where I would go back to in this case as well, how do you start off your relationship with your patient? I outline it very clearly. My number one goal is that this patient is safe, my number two goal is that they are healthy, and my number three goal is that they live as long as they can. There are things that we can control and things that we can’t control. One of the things we can control is screening for cancers. We can’t control things that happen where they become ill in between their routine examinations. The other thing about communication is I do a very big dose of that at their yearly physicals, which is when I document all my cancer screenings. I go by year, I go by patient; I redo the family history. I don’t want to miss anything. A busy physician has a lot of patients and I may not remember, so I have to document that. At the same time, I’m trying to develop a communication with that patient about their body. It doesn’t mean we need to be best friends, but I want to make sure that they’re safe, and I think that provides quality. 

ADUBATO:  What could have or should have been done given everything you just said, doctor? What could have or should have been done by this physician to potentially have avoided this outcome? 

LEFKOVITS:  Many things. First, you start at age 50. Actually, you can go back to age 45, and I don’t have those particular notes, but if you go back to age 45 that’s when we start talking about colon cancer screening. At age 45, a patient can get a variety of different types of colon cancer screenings. They can get cards that they bring home or they can get a box kit. I’m not going to go into those details unless you want me to. They can go to a colonoscopy, which would be typically patients who have a family history of colon cancer, and those can be done between 45 and 50. By the time that patient reached the age of 50, that’s a big old discussion at their physical or at their next office visit — time to do your colonoscopy. That’s not when you’re having symptoms. That’s when you’re having no symptoms because the colonoscopy detects and removes small polyps that are in the colon. By removing those polyps, you remove your risk of cancer. This patient apparently had multiple visits where she noted that there were visits but there were no notes. I don’t know what happened there exactly, but if that’s a failure of documentation, then that’s on the office or physician’s end of things. Where is that documentation? Those were additional opportunities to then recommend the colon cancer screening. Again, it doesn’t need to be a colonoscopy, but it needs to be something, and in this case with the patient having rectal bleeding, I am 99% sure that if she had done even a stool card, that stool card would have been positive, which would have led to a GI evaluation that would have led to the earlier detection of her abnormality. What would that abnormality have been? It could have been a polyp, it could have been a growth. Maybe it could have been removed. You never know in hindsight, but it does seem very realistic that this having been caught early would have been potentially lifesaving for that patient.

STEVE ADUBATO:  Do you know what the outcome was in this case?

LEFKOVITS:  Yes.  

STEVE ADUBATO:  Share it with us, please.

LEFKOVITS:  She was diagnosed with rectal cancer, which was metastasized. This was a young patient who had a very bad outcome. I don’t know the eventual outcome, but I know she suffered quite a bit. 

STEVE ADUBATO:  Final message to all the physicians listening right now to the MagMutual Podcast who can really take something from this case study that will help them, regardless of what their specialty is, please.

LEFKOVITS:  Well, two things. One, again, going back to that science and art of medicine. In regards to the science of medicine, document, document well, and be meticulous about your screenings with patients. Number two, the art of medicine, try to develop good communication with your patients. Make sure you ask them open-ended questions. “Did I answer all of your questions? Is there anything else you need today?” Make sure you get your goals met, which is, number one, patient safety, and number two, trying to keep your patients healthy. 

STEVE ADUBATO:  Doctor, you just helped an awful lot of your colleagues in this conversation. I imagine that regardless of what one’s particular specialty is as a physician, these issues come up, these challenges come up, and these best practices are relevant. So thank you very much.

LEFKOVITS:  It’s my pleasure.

STEVE ADUBATO:  Thank you, Doctor, so much, for joining us. On behalf of everyone at MagMutual, this has been the MagMutual Podcast. I’m Steve Adubato.  Thank you so much for listening.