Case Studies

Lesson learned

Failure in Follow-up Care Delays Cancer Diagnosis

Case Summary

A 67-year-old patient with a previous history of prostate cancer was referred to Dr. B, an otolaryngologist, for evaluation of a mass in his jaw, in year 1. The patient was largely asymptomatic, but he reported experiencing intermittent pain in his ear for almost two years. The examination by Dr. B was consistent with the radiographic findings of a mass in the parotid gland involving the deep and superficial lobes.

Dr. B explained to the patient the tumor's commonly benign presentation and its usual course and treatment, including eventual surgery. As per his standard office procedure, the surgeon recommended that the patient schedule the surgery and return to the office within the next couple of months to prepare for his scheduled procedure. The patient did not schedule the surgery or any follow-up visits as instructed. Instead, he delayed returning to Dr. B's office for two years and, when he did return, his symptoms were more significant. Upon his return, the patient also described numbness in his jaw area. An MRI revealed that his tumor had grown significantly. The patient immediately underwent a parotidectomy. Pathology diagnosed a malignant acinic cell carcinoma. In addition, due to the technical difficulty of the procedure and to facilitate the tumor's removal, the patient's facial nerve was intentionally transected, which later required an oculoplastic procedure to repair the weakness in his upper eyelid and forehead.

The patient underwent radiation treatment following the surgery, but he declined to receive chemotherapy. After his radiation treatment, he had no detectable residual disease; however, he developed a recurrence in his left jaw approximately twelve months later, requiring mandibular reconstruction surgery. After a lengthy post-operative recovery, he was first believed to be disease-free, but he later learned he had metastatic disease. He transferred care to an oncologist for palliative care.

The patient filed a malpractice claim against Dr. B, alleging negligence for Dr. B's failure to diagnose and treat his parotid gland tumor when the surgeon first saw him in the office. He claimed that the delay in diagnosis enabled the cancer to become metastatic, requiring a more expensive surgery and a severely reduced life expectancy.

The case settled in the mid-range.


Dr. B recommended that the patient schedule surgery during the patient's first office visit in year 1. He asked the patient to return to the office within a couple of months to prepare for the upcoming procedure.

The patient did not return to the office, and the surgeon's office did not have a system in place to track patients who failed to schedule follow-up appointments. Due to the lack of a tracking system, the patient was lost to follow-up, and his tumor size increased an appreciable amount.

The surgeon recommended surgery, but the patient did not schedule the surgery or any follow-up visits as instructed , which was a mitigating argument in negotiations that helped moderate the amount of settlement that was ultimately reached.

Risk Management Takeaways

Managing patient appointments is an essential function of any office practice. A poorly managed appointment process poses a risk to patient safety and continuity of care. Practices should determine their appointment management system. Once the process has been defined, a policy should be written. All staff members involved in the process should receive education on the steps and the importance of these steps to assure patient safety and the practice's financial stability.

  • The following key risk management takeaways will help you establish an effective appointment management process in your practice.
  • Implement a process that ensures patient's schedule recommended appointments, surgeries and pre-op visits at checkout.
  • Maintain a list of patients who do not make recommended follow-up appointments or book surgeries at check-out. Make attempts to contact patients until appointments are scheduled.
  • Educate patients about their treatment regimens and the importance of follow-up. Evaluate the patient's comprehension and reinforce teaching as needed.
  • Notify providers when patients either no-show or cancel without rescheduling their appointment. Follow the provider's recommendations on follow-up with the patient.
  • See MMIC's practice tips Appointment Management: Missed and canceled appointments, referrals not completed and Results Management: Tracking Diagnostic Tests and Referrals for more information about setting up processes in your practice.