This is an actual TMLT medical malpractice case. It involves a pain management specialist who was treating a patient for back pain. This presentation illustrates how action or inaction on the part of the physician led to allegations of professional liability, and how risk management techniques may have either prevented the outcome or increased the physician's defensibility. The case has been modified to protect the privacy of the physician and the patient.

1. Failure to communicate
MRI Results
Case Closed
A case study to help
you manage risk.

2. presentation
A 56-year-old woman came to a pain management
specialist in July 2007 for treatment of back pain.
The patient had a history of chronic obstructive
pulmonary disease.

3. presentation
In August 2007, the pain management specialist
ordered an MRI of the thoracic spine. In addition
to some spinal pathology, the radiologist noted a
“possible 9 mm right lung nodule.” The radiologist
recommended a CT scan if clinically warranted.

4. presentation
The patient’s next appointment was delayed due to
bad weather and scheduling conflicts. She next saw
the pain management specialist in October 2007.
There was no mention of the pulmonary nodule.
The patient had two more office visits that year and
14 office visits in 2008. The patient saw either the
pain management specialist or his advanced practice
registered nurse (APRN).

5. presentation
In July 2009, the APRN reviewed the chart and
noticed the MRI report. She discussed the MRI
results with the patient and told her to discuss them
with her primary care physician. The radiology report
was faxed to the patient’s primary care physician.

6. presentation
The patient’s primary care physician ordered a CT
scan, which revealed a right paratracheal mass.
The mass was biopsied and found to be a small
cell carcinoma. The patient was treated with
chemotherapy and radiation.

7. presentation
By March 2010, she was in remission, but her COPD
worsened. She was hospitalized several times in
2010 with weakness, chest pain, and difficulty
breathing.

8. presentation
The patient was found dead at her home on April
14, 2011. The cause of death was listed as multi-
system organ failure. Lung cancer was listed as a
contributing factor.

9. Allegations
A lawsuit was filed against the pain management
specialist, alleging delay in diagnosing the patient’s
lung cancer. The plaintiffs claimed the delay reduced
the patient’s prognosis for survival and ultimately
caused her death.

10. legalimplications
Although the lung nodule was an incidental finding
on the MRI, it was difficult to argue that the pain
management specialist did not have a duty to act on
the findings by:
• discussing them with the patient,
• sending them to her primary care physician, and/or
• ordering the CT scan.

11. The pain management specialist testified that he
should have notified the patient.
legalimplications
Defense experts who reviewed this case agreed.
However, defense oncology experts argued that the
“late” diagnosis did not affect the patient’s prognosis
and did not cause her death. The prognosis for small
cell lung cancer is poor, regardless of the timing of
the diagnosis.

12. This cancer responds well to the initial round of
treatment, as in this case, but it typically recurs and
causes death within another year. Defense experts
argued the patient was in remission and likely died
due to an exacerbation of her COPD.
legalimplications

13. Despite the strong causation defense, the failure
of the pain management specialist to act on the
MRI results was difficult to overcome. This case was
settled on behalf of the pain management specialist.
disposition

14. The following processes can help address the
potential for an allegation of delay in diagnosis and
treatment.
• Develop a tracking system for all labs, diagnostic
studies, and referrals. This can be done through a
paper log or through the electronic medical record.
• Initial and date all laboratory and diagnostic
reports upon your review of the report. If hard copy
reports are reviewed, make sure documents are not
filed before your review.
Risk management
considerations

15. (continued)
• Document follow-up actions, if abnormal results are
noted on the laboratory/diagnostic report.
• Document the discussion with the patient about
diagnostic abnormalities. Each attempt made by a
staff member to contact the patient with follow-up
instructions should be documented.
• Consider a referral to a specialist for questionable
diagnoses.
• Establishing these processes can maximize a
physician’s defensibility and prevent a delay in
diagnosis and treatment for the patient.
Risk management
considerations

16. disclaimer
This closed claim is based on an actual malpractice
claim from Texas Medical Liability Trust. This case
illustrates how action or inaction on the part of
the physician(s) led to allegations of professional
liability, and how risk management techniques may
have either prevented the outcome or increased the
physician’s defensibility. This study has been modified
to protect the privacy of the physician and the patient.
© Copyright 2016 TMLT.

17. about tmlt
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in its care, Texas Medical Liability Trust (TMLT)
provides malpractice insurance and related products
to physicians. Our purpose is to make a positive
impact on the quality of health care for patients by
educating, protecting, and defending physicians.
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