I felt sad when I went to make rounds in the hospital.

One of my patients, a colleague, had been readmitted in poor condition for recurrence of a primary lung sarcoma.

I spent a few minutes examining Dennis and chatting.  He then, with a quizzical look, said, “Jim, I’m going to have to sue you.  I know I’m dying.  My wife Alice and the kids are still pretty young.”  He saw my look of surprise and added, “You know, I don’t have much life insurance or other very significant funds for them to live on.  It’s nothing personal.  I know you’ve given me good care, but my wife is upset and tends to blame you for the outcome.  I guess the hospital and others will be named.”

There wasn’t much more for me to say at the time except, “Dennis I can find another attending for you if you’d like.”  He replied, “No, I want to stay with you.”

Dennis was a well liked family doctor.  About five years earlier a “coin lesion” was discovered on a chest X-Ray.  This 2cm spot in the right upper lobe had a smooth rounded border and didn’t contain calcium.  A CT scan showed no enlarged lymph nodes and no other spots elsewhere.  A needle biopsy of the spot was not diagnostic.  We knew the spot was new because an X-Ray five years earlier was normal.  He hadn’t traveled to an area where Valley Fever or other fungal infections were common.

At surgery, the right upper lobe was removed along with local lymph nodes.  The lesion turned out to be a primary lung sarcoma, a quite unusual type of lung cancer.  One of the lymph nodes was positive.  We sent Dennis to local experts on sarcoma and several opinions from cancer specialists were obtained.  The consensus at that time was that sarcomas don’t respond very well to either chemo or radiation therapy, but after further opinions, Dennis had a series of radiation treatments.

After that it was waiting.  For three years, there was little change.  Then fluid began to accumulate in the right lung cavity and some density in the area of radiation (often radiation changes).  I drained the fluid from Dennis’ chest several times.  No cancer cells were found.  After more signs of progression but no proof of recurrence, I sent Dennis to the top academic chest surgeon in the area who admitted Dennis to the hospital.  After more conferencing there, he attempted a complete removal of the right lung in order to try to remove all the residual tumor.  Dennis had a very stormy post-op course and required ICU care and a ventilator for almost three months before being successfully weaned off.  However, the sarcoma was never completely removed, thus still progressing.

He was then transferred back to my hospital where I met with Alice.  Somehow I was the focus of her anger about her husbands tragic illness, and extensive suffering especially over the past year with heroic attempts to deal with the recurring sarcoma.  We had social service and others involved.  To say the least it was awkward to remain involved knowing that a legal threat was in the air.

Hospice met with Dennis and Alice.  They mercifully stepped in and provided their healing palliative care.  Although plans were made to have hospice at home, Alice balked.  After a few weeks Dennis died peacefully in a hospital hospice unit.

As I think about Dennis and Alice, I wonder what I could have done better in communication.  I’m not sure.  I did find out that Alice tried to find a plaintiff’s attorney to file suit.  They had several experts review the records, but they all advised her that she had no reasonable grounds to forge ahead legally with her complaints.  I felt Dennis’ care had been good and wasn’t very concerned, but was reminded that it often takes several things to bring about a medical malpractice claim:  a poor outcome, communication breakdown, anger, and a mistake or oversight of consequence.  Our tort system is cumbersome and expensive.  It’s not the major factor driving medical costs these days, but is significant and will need reform.  But can we ever get there?

Jim deMaine is a retired pulmonary/critical care MD. He gives frequent talks to patients about end of life planning. You can follow him at End of Life – Thoughts from an MD, where this post first appeared.

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13 Responses for “Doctor Versus Doctor”

  1. Dr. Mike says:

    There are significant forces arrayed against the idea of reforming the cancer that is the tort system. They claim that “reform” has failed when they know good and well that economic caps are anything but reform. Meanwhile thousands go without relief due to the barriers to quick resolution of actual mistakes while other’s win the lottery, and the rest of us suffer the burden of risking costs and needless testing and overtreatment.

  2. southern doc says:

    I doubt if you could have done anything better.

    The patient was obviously trying to use the legal system to correct the results of his years of poor financial planning. He was the one behind the threatened lawsuit, and he obviously had skillfully managed to deflect his wife’s anger at himself onto you.

    Serious illness does strange things to people, but it doesn’t turn nice people into assholes.

  3. DeterminedMD says:

    WTF!? I was waiting for a punch line or other kind of “ha, got ya” moment, but not to be. If this is how our own colleagues are thinking and acting, we are doomed! Again, how can we help our society if people think they CAN’T DIE?!

  4. Dr. Val says:

    @southern doc hit the nail on the head: “The patient was obviously trying to use the legal system to correct the results of his years of poor financial planning.”

    And that’s the same reasoning behind many med mal suits I’m sure. “Loser pays” is the best way to disincentivize frivolous law suits. Bring on tort reform!

  5. MD as HELL says:

    The waiting and the draining of fluid several times I believe are viewed by the wife as lost opportunity. Waiting fed the denial of the patient and family. It was what they wanted to hear at the time, but fueled anger when the disease became clearly fatal.

    Being sued can make your medicine more defensive. The real lessons are reassessing how you manage the patient and family as people facing an illness and how you view your own role as physician in the care of people, more aware of your strengths and limitations. The threat of lawsuit is a given in every encounter. Bad outcomes will always draw interest. Patients and families are easily “lawyered up”.

    The sarcoma patient already lost one bet, so he was going to make another. Totally human. But the loser should pay for the insult.

  6. Aprilette says:

    This is a sad story and I wish it had a different ending but reality is really something else- so cruel! I guess Dennis’ wife had a really hard time accepting what happened to her husband. You were just caught in the middle of her frustration and agony over her husband’s suffering. I’m sorry for what happened.

  7. Cory says:

    I agree with fid72, looking at the tragic case purely from the standpoint of medical malpractice, the system did what it was supposed to – prevent an ostensibly frivolous suit. Doctor practiced good medicine, patient suffered unavoidable bad outcome, system required expert validation which could not be obtained.
    Isn’t that what is supposed to happen?

    • DeterminedMD says:

      Of course, but just because it happened here does not mean it happens over 90% of the time. We as doctors should feel blessed because the lawyers involved in this case saw the inappropriateness and this will pervade nationally? Again, I wait with bated breath for all these commenters who have been frivolously sued to tell us how it was no big deal.

      Fascinating how it is almost always those who AREN’T doctors, who have never been sued, telling us how to think and feel!

      And the point I take from this post is, why did a colleague act so passively and indifferently when he knew his family would try to pursue a suit on his behalf after his death. Hey, if someone is going to do something representing me, and I have a say differently, then I am going to SAY SOMETHING on my behalf to note otherwise!!

      • southern doc says:

        “if someone is going to do something representing me, and I have a say differently, then I am going to SAY SOMETHING on my behalf to note otherwise!!”

        That’s why I’m convinced the patient was the one behind the suit originally, and had over time manipulated his wife into deflecting her anger from him onto the treating physician.

  8. Cory says:

    DeterminedMD;
    Talk all you want about tort reform – and by the way I have been a doctor for 35 years, not that its important – but one salient fact remains that was illustrated here.
    Suits can not be filed unless doctors, that’s right doctors, say there is some merit. It wasn’t the lawyers who we should feel thankful for in this case, it was the “experts” who weren’t
    Change the system all you want but someone in our profession has to give the go ahead to any suit no matter how frivolous (with one or two extremely unusual exceptions).
    At some point in any suit that you think was ridiculous (an dIm sure just like me you can cite many), all those 90% you refer to, someone from our profession made it possible.

    • DeterminedMD says:

      “Experts” as you deem them, until proven otherwise, work for who pays them, which is why I have little respect for “hired guns” as I prefer to call them.

      You can find anyone to say what you want, depending on the money and alleged level of expertise such “expert” will have to defend in cross examination. Funny, I read the post as alluding that no lawyer would accept the case. Perhaps your interpretation is more accurate, but don’t tell me the wife could not find an expert and adjoining lawyer to try to make our above colleague look incompetent. She just realized her folly?

      My anger is with the patient. He failed his doctor and his family! Sorry if that is a harsh comment.

  9. Cory says:

    “Experts” as you deem them, until proven otherwise, work for who pays them, which is why I have little respect for “hired guns” as I prefer to call them.
    You can find anyone to say what you want, depending on the money and alleged level of expertise such “expert” will have to defend in cross examination.

    I don’t disagree with that comment. Please tell me how we should demand tort reform from the public, or have our own profession even ask for it if that statement is true.

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