Though a patient without insurance coverage may seem to appreciate a physician taking a simpler approach to a medical issue, you can be sure the doctor will get no benefit from his or her good intentions if things go wrong.
A 56-year-old woman visited Dr. PS, a plastic surgeon, for a nodule on her right forearm. On examination, Dr. PS found a large right volar wrist mass consistent with a possible ganglion cyst. Dr. PS aspirated the mass and found no fluid or gel. He told the patient what he had found and discussed treatment options with the patient and her husband. Dr. PS noted in his chart: “The patient who is unfunded wished to have the mass removed under local anesthesia in the office.”
Upon making the incision that same day, Dr. PS found a 2×2 centimeter mass resembling an encapsulated nonmalignant tumor involving the median nerve. With the wound open, Dr. PS discussed with the patient whether to proceed with excising the tumor, which would involve cutting (and later repairing) the nerve. In his operative report, Dr. PS noted: “Patient agreed and (the) mass was excised and because of the clinically non-malignant and well encapsulated appearance as well as to avoid (the) cost of pathology, the mass was not sent to the lab with the patient’s agreement.”
When the patient returned to Dr. PS two days later, she had experienced the expected loss of sensation over the median nerve area of her hand. Dr. PS scheduled the microsurgery nerve repair in 11 days’ time at the surgical center.
With the patient under general anesthesia and using an operating microscope, Dr. PS performed the primary epineural repair of the median nerve with the patient tolerating the procedure well. In follow-up appointments over the next several days and weeks, Dr. PS noted that the incision was healing well. By seven weeks post-op, Dr. PS noted that Tinel’s sign was positive, sensation was further distal, and range of motion was near normal. Dr. PS noted similar progress three weeks later and at that time, directed the patient to return in six months. He prescribed Vicodin as needed.
Instead of returning to Dr. PS, the patient went to see Dr. OS, an orthopedic surgeon, as she did not feel she was getting better eight months after the surgery. Dr. OS noted the patient could not feel in her right hand and that she could not do her hair, cut food, hold on to utensils, or open a jar.
Dr. OS told the patient that since no pathology study was done on the removed mass, he recommended an oncological workup. As for the nerve itself, Dr. OS believed the patient would require another surgery. After a neurologist and neurosurgeon examined the patient, however, the neurosurgeon told her there was little to be gained from further surgery and that it could take up to 18 months before they would know whether function would return.
Though the mass apparently was not cancerous, the patient sued Dr. PS for her ongoing injuries. Her attorney explained his theory of negligence in a “notice of intent to sue” letter to Dr. PS: “We have been advised that injury to the nerve should have been avoided at all costs and the even though a cyst may have been surrounding the nerve, the cyst should have been partially dissected and appropriately biopsied to determine whether it posed any health risk to the patient.”
Dr. PS and the patient resolved the legal dispute informally.
If tempted to pursue an alternate treatment plan based on a patient’s financial situation, a physician should assess whether such a consideration might be clouding his or her clinical medical judgment.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.