Medicolegal Issues in Patients with Breast Disorders
Pia Natalya Reyes; Wilfredo B. Reyes; Ma. Angelica Rivera; Kathyrn Roa; Ma. Lorena Rodriguez; Aileen Charisse Romulo; Carlo Rico Sace; Anna Carmela Sagcal;,Joselito Sanchez; Carlos Alfonso Santos; Don Reginald Santos; Florence Yul N. Saquian; Jan Harold Sial; Ma. Loida Sibunga; Paolo Antonio Silva UPCM Class 2002 (Year II, 1999) Reynaldo O. Joson, M.D. (Facilitator) 1999
Case 1
I. Scenario
Ms. R, 42-year-old bank employee, visited a Dr. Z complaining of a right breast lump with tenderness. After Ms. R told him of her complaint, Dr. Z prescribed analgesics right away and advised her to come back if symptoms progressed. Ms. R did not come back and died several months later. Cause of death: breast cancer with brain metastasis.
II. Identification of medicolegal issues (physician's legal responsibilities and liabilities)
The doctor failed to elicit the proper history.
III. Analysis of medicolegal issues
When the patient told him her complaints, Dr. Z did not ask her further questions which could have helped in the diagnosis of the breast lump. The issue here is NEGLIGENCE. In every patient consultation, the doctor must elicit a complete and thorough history as well as perform adequate physical examination before giving any plan of management. History is helpful in arriving to a diagnosis in 70-75% of the time, and therefore, is very helpful in making a correct diagnosis. Family history, environmental exposure, as well as occupational history should have been elicited during the visit. These factors are crucial in the diagnosis of the breast lump.
IV. Suggestions on how to solve medicolegal complications
Since the damage has been done, the doctor should acknowledge his fault (and more importantly learn from it). The doctor should also consider the breast lump as breast cancer as one of the differential diagnoses. He should also recommend to the patient to get a second opinion from another doctor if the patient wishes. This does not mean that the doctor is incompetent in his practice but is a sign of humility for the benefit of the patient.
V. Suggestions on how to prevent medicolegal complications
The doctor should always elicit a complete and thorough history before anything is done or given to the patient.
Case 2
Mrs. D consulted her gynecologist Dr. P complaining of what she describes as a "lump" in her right breast. The physician elicited a good history. The patient had no prior nor familial history of any cancer. She hasn't been exposed to environmental or occupational hazards. Dr. P requested mammogram right away after feeling the "lump" at the right upper quadrant. Radiologist reported "No calcifications seen in either breast. Both breasts are dense suggesting fibrocystic disease. There is no evidence of malignancy." Dr. P prescribed analgesics to Mrs. D to relieve pain and advised to follow-up after a month. Patient returned months later with diagnosed breast cancer with metastasis.
The doctor relied on ancillary procedures rather than on physical examination. The doctor failed to perform a complete and thorough physical examination.
III. Analysis of the medicolegal issues
The doctor elicited a thorough history, which is very commendable, since 70-85% o f the time the diagnosis can be gotten from the history. However, the doctor relied too much on her history and failed to perform a thorough physical examination which is equally important in diagnosing the patient. She just palpated the lump and recommended mammogram right there and then. She failed to palpate the axillary and supraclavicular nodes which are most common sites of metastasis. She also failed to describe the lump which could have been helpful in her differential diagnosis. She relied on the mammogram to detect the possible calcifications as indication of malignancy. Since there was none, she did not consider the possibility of breast cancer. This is also a case of NEGLIGENCE, this time neglect to perform a physical examination.
The doctor should also consider the breast lump as breast cancer and treat it as such. Treatment is usually an operation. The doctor should also recommmend to the patient to get a second opinion from another doctor if the patient wishes. This does not mean that the doctor is incompetent in his practice but is a sign of humility for the benefit of the patient.
The doctor should always elicit a complete and thorough physical examination before anything is done or given to the patient. Furthermore, the doctor should not rely on ancillary diagnostic tests since some of the malignancy will not manifest in these tests and could lead to a wrong clinical diagnosis and plan of management.
Case 3
Mrs. E consulted Dr. J for a right breast lump. After getting a complete history and performing a thorough physical examination, Mrs E. was advised to have an diagnostic operation since the doctor is not very sure with the diagnosis based on his history and physical examination. The patient consented and the operation was done. While performing the operation, Dr. J discovered that the breast lump was malignant. He did not hesitate to remove the malignancy without telling the patient beforehand.
The doctor failed to get consent from the patient or patient's kin regarding the removal of the malignancy.
It is commendable that the doctor has elicited a complete history and performed a thorough physical examination. He also asked the patient's consent regarding the operation which he considers as critical in confirming his initial diagnosis. However, removal of the malignancy also necessitates the consent of the patient. It does not follow that if the patient consented to a diagnostic operation, she also consents to the removal of the malignancy. The doctor could have even told the patient or her nearest kin regarding his procedure which included the removal should he find one. This is a case of MALPRACTICE as well as NEGLIGENCE. Malpractice because he performed a procedure which does not follow standard operating procedures, that is, seeking patient's consent. Negligence since he failed to seek the consent of the patient or her nearest kin.
Since the doctor has already removed the malignancy, he should make sure that the patient goes back to her normal activities. He should also make sure that he remove the metastasis in the nodes if there are. Furthermore, the doctor should make sure that the operation he performed is aesthetic and does not leave the patient with psychological or social problems.
The doctor should always seek the consent of the patient before doing any procedure. This is to make sure that the patient is willing to have something performed on her breast. The doctor is also responsible to explain every procedure done or is to be done to her to make sure that the patient understands the surgical treatment performed on her.
Legal Basis of Medical Practice. Macmillan Publishing Co., New York, 1994 Lectures in Internal Medicine by Dr. Dans, 1998.
Comments or Questions?
Title: Full Name:Email: Comments or Questions:
Medicolegal Issues Folder HIISE-Guidelines and Format GS I TeleBreast Program Development Status
GS I email: gs1pgh@mail.upm.edu.ph RJoson email: rjoson@pacific.net.ph