Case Studies

Failure to Follow up on Breast Lump

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On June 14, a female patient presented to her PCP with a palpable breast lump, which the PCP estimated to be approximately 1 x 3 cm. in size. The PCP recommended obtaining a mammogram and follow-up in three months. The mammogram was performed on June 25. The mammogram showed clustered microcalcifications that were not present in the prior study; there was no evidence of a cancerous lesion. The radiologist recommended a repeat mammogram in six months. The PCP noted on the mammogram report on June 28 that he left a phone message at the patient’s house asking her to call him back. He further noted that the plan was to repeat a mammogram in six months or offer a surgical referral for a biopsy; however, he did not order a repeat mammogram or offer a surgical referral to the patient.

The patient was next seen by her PCP five months later, on November 27. The visit was for a condition unrelated to her breast lump. The PCP did not inquire about the lump or do a breast examination. The patient was seen again on January 25 of the following year for an unrelated problem. No action was taken regarding the breast lump.

On May 2 of the following year, the patient’s husband called the PCP’s office and reported that his wife’s breast lump was much larger and dimpling the skin. The PCP made an immediate referral to a breast surgeon. In the referral letter, the PCP referenced the prior indeterminate mammogram and stated that he had recommended an ultrasound and a follow-up mammogram in three months. He noted in the letter that he had urged the patient to consider a surgical referral and that the patient had declined all of his recommendations.

The patient underwent a biopsy, which confirmed infiltrating ductal carcinoma. A modified radical mastectomy was completed, which demonstrated that 2 of 11 lymph nodes were positive for metastatic disease.

The patient filed a claim alleging that the PCP was negligent in his treatment of the patient and that this caused a delay in her diagnosis of breast cancer. The patient’s attorney claimed the PCP was obligated to obtain a definitive breast lump diagnosis promptly. He was also obligated to return the patient to the office as planned and perform breast examinations. The patient further alleged that due to the delay, her cancer metastasized, and her condition and long-term prognosis for survival worsened.

During discovery, it was determined that the PCP never made the recommendations to the patient represented in his referral letter to the surgeon on May 2nd. He admitted during testimony that he never advised the patient to undergo an ultrasound, never recommended a repeat mammogram, or that the patient see a surgeon.

When the patient presented to her physician’s office with a palpable breast lump, her PCP ordered a mammogram, which the patient completed promptly. The mammogram was interpreted, and the radiologist recommended a repeat mammogram in six months. The provider noted on the mammogram that he had left a message at the patient’s home asking her to call him back; however, he did not follow up when the patient did not return his call. While the provider planned to order a repeat mammogram or offer a surgical referral, he failed to do either. The office did not appear to have a process to follow up on the provider’s treatment plan.

The patient was seen by her physician two times for issues unrelated to the breast lump during the next eleven months; on both visits, the provider did not inquire about the lump, order a repeat mammogram or offer the patient a referral to a surgeon. A review of the patient’s prior history before these office visits would have alerted the provider to the missing follow-up.

When the patient’s husband called the provider to inform him that the lump had grown, the provider made an immediate referral to a breast surgeon and made the decision to falsely claim in the referral letter that he had recommended follow-up that the patient declined.

The physician’s failure to follow up with the patient on the breast lump and his fraudulent notations in the letter to the surgeon made defending the case challenging. Therefore, MMIC moved to settle the case.

• Develop policies outlining the ordering provider’s responsibility to reconcile all ordered tests and initiate follow-up for abnormal and incidental findings.
• Set up systems in office practices to track diagnostic tests ordered by providers to ensure the tests are completed, the results are received, and the patient is informed of the results.
• Be sure that patients are notified of normal and abnormal test results. Patient portals make test results more readily available to patients.
• Assist patients in setting up access to the patient portal.
• Collaborate with your resources, such as risk management, legal, and clinical leadership to assess and plan for the appropriate steps.
• Develop a standardized disclosure policy and procedure that includes event reporting, disclosure procedure, staff training, collaboration with risk management and legal, applicable state apology and peer-review laws, and shared decision-making at a minimum.