Episode 001: The Case of the Cancelled Appointment

Brian F. : Hello and thanks for joining us. My name is Brian Fortenberry. We're going to be looking into a closed claim case here today. Before we get into the discussion and review of this, I'm going to lay out the story and we'll start with that.

Henry Jackson, a 50-year-old male patient, presented to the ER at a hospital near his home, where he was seen for cold symptoms and progressively worsening headaches that were not responding to medication.
The ER physician ordered a CT scan for Mister Jackson. The scan showed sinusitis in the ethmoid and sphenoid sinuses, but the maxillary and frontal sinuses appeared clear. The radiologist report also noted a small amount of erosion of the bone in the ethmoid area. The radiologist's impression was maxillary ethmoid sinusitis versus mass.
The ER physician and the radiologist discussed the fact that this was an unusual sinus pattern for someone without a history of sinus disease, and without having sinus disease elsewhere. The ER physician instructed Mister Jackson to follow up with an ENT physician in two weeks, to make sure that this was nothing more serious than an atypical sinusitis.
Mister Jackson presented to the office of an ENT physician three days later. The ENT physician noted that Mister Jackson's headaches had started five days earlier, and that the headaches had worsened over that time, including the time since Mister Jackson had presented to the ER.
The ENT physician reviewed the CT scan from the ER presentation, and noted the scan showed complete opacification of the left sphenoid, and near total opacification of the right sphenoid sinuses, with no other significant sinus pathology.
The ENT physician assessed Mister Jackson's condition as severe acute sphenoid sinusitis with excruciating pain and pressure with possible early meningeal signs, and immediately admitted Mister Jackson to the hospital.
An MRI was taken at the hospital and the radiologist impression were complete opacification of a somewhat expanded appearing left sphenoid sinus, suggested an appearance of the sphenoid sinus mucocele, extensive but partial opacification in the right sphenoid sinus and posterior ethmoid air cells bilaterally, indicative of chronic sinusitis in an otherwise normal study.
The next day, Mister Jackson informed the ENT physician that he felt great and wanted to go home. The ENT physician noted the MRI revealed a probable mucocele at sphenoid, sinusitis ethmoid sphenoid at right. He also noted that Mister Jackson's condition had improved, so he discharged him from the hospital.
The medical chart indicates that the ENT physician wanted Mister Jackson to make a follow-up appointment within two weeks, at which time another CT scan would be taken. Unfortunately, the day after discharge from the hospital was the last time the ENT physician had any contact with Mister Jackson or his family.
Mister Jackson presented to the office of his PCP approximately one year later, for treatment of a severe intermittent sinus headache that had returned. A CT scan taken a few days later showed that a neoplastic process is a likely consideration. Biopsies were taken and an MRI was performed, and both confirmed that Mister Jackson had a sinus adenocarcinoma.
Mister Jackson died approximately six months after the diagnosis. His estate filed suit against the ENT physician and against the radiologist who read the CT scan during the initial hospitalization. The ENT physician initially believed that Mister Jackson had simply failed to make a follow-up appointment as instructed. However, during the lawsuit discovery process, the attorney representing the ENT physician learned that although the appointment had been made by Mister Jackson, it was canceled by the ENT physician's office because he had a family emergency that required him to be out of town for a week.
The records did not identify which staff member in the ENT physician's office had called Mister Jackson to cancel the appointment, or how the matter of rescheduling the appointment was addressed with the patient. The record showed only that the appointment was canceled. No new appointments were made for Mister Jackson.
Well, joining us today to discuss this case is J Baugh. J, welcome.

J Baugh: Thank you, Brian. Good to see you.

Brian F. : J, before we even get into this to start discussing the facts of the case and some of the things that potentially went wrong here, tell us a little bit about yourself.

J Baugh: Well, my undergraduate degree is in accounting, and after that I took the CPA exam and became a CPA. And then after that, I went to law school, passed the bar and became an attorney. So I've been a CPA and an attorney for several years now.
I've been at State Volunteer for about 17 years, and I've been in the claims department that entire time. So I've been a claims attorney here at the State Volunteer since the year 2000.

Brian F. : Wow. So you certainly have some knowledge about this case and everything that went on. Sounds like a pretty complex case that some unfortunate circumstances came up with.
Let's start with this. Did the jury take into consideration the fact that the ENT physician was not aware of the appointment cancellation, but with that week out of the office and the staff canceling that, were they aware of that? And what about the radiologist named in the suit itself?

J Baugh: Well, the jury really did not take that into consideration about the fact that the appointment had been canceled by the ENT physician's office, because the ENT physician actually did not go to trial. We actually settled his part of the case out prior to the trial, so the jury would not have been told about that cancellation of the appointment, because the radiologist was the only one who went to trial. So canceling that appointment would not have been relevant to the radiologist's case, so the jury was not told about that.

Brian F. : Okay. That does make sense. They obviously didn't have a tracking system in place for this appointment, so a faulty tracking system obviously played into this and the outcome of the case.
If they had had a better process in place, a better tracking system, would that have made a difference potentially in the outcome of the case, or is that really important?

J Baugh: Well, proper tracking systems are obviously very important when it comes to trying to keep things like this from falling through the cracks. But this case is a little bit different than the case that we normally see. It has an exception that I think ... well, I'll spend just a little time highlighting here, that you don't see in most cases, because in this case the ENT physician had to cancel an entire week of appointments because he had a family emergency that caused him to be out of town for a week.

Brian F. : And that couldn't really be expected obviously.

J Baugh: Absolutely. That was something outside of his control.

Brian F. : Sure.

J Baugh: He really couldn't do anything about that, so he had to cancel an entire week of appointments in order to attend to that family emergency. So when something that is so out of the ordinary like that happens, it's important for someone in the management of the organization to take a step back, maybe take a look at the situation to see if something out of the ordinary needs to be considered, to address an unusual situation such as this.
Proper tracking systems are great for the day-to-day operations of a medical practice, but when you have something as unusual as this that happens, you need to take a step back and see whether there's something else that needs to be done in a situation like this.
So I think maybe if that had happened in this case, if they had looked at it a little differently, then perhaps a patient's appointment would've been rescheduled.

Brian F. : I got you.

J Baugh: You know, we hear physician say, occasionally, they'll say that patients should have some responsibility in their own healthcare. And that's obviously true, but in this situation, this case is a little different, again because it was the physician who canceled the appointment.
So you don't have a situation here where the patient missed an appointment and didn't bother to tell anyone, or they were noncompliant with their medication or something like that, which is a typical situation that we-

Brian F. : Right, that comes up from time to time.

J Baugh: Absolutely.

Brian F. : Sure.

J Baugh: But this isn't a situation like that. It's quite different because it's the physician who canceled the appointment, not a no-show by the patient.
So I think it would be difficult for us to find a physician who would be willing to go to trial, testify as an expert, and to say that a physician who canceled an appointment and didn't reschedule it, was acting within the standard of care. That would've been a pretty tough row to hoe with that one.

Brian F. : That's going to be challenging to find on your part, for certain.

J Baugh: Absolutely.

Brian F. : This case also points to the need for a physician to discuss with the patient, and really the document, the reasoning for test and studies and things of that nature. Do you feel the patient realized the importance of this follow-up CT scan that could've possibly changed the outcome? Because maybe the patient didn't completely understand, or didn't appreciate the seriousness of this, and could the patient have interpreted the cancellation by the physician's office may be just as, "Hey, they don't see this as that important, so they didn't offer to go ahead and reschedule it immediately, so maybe the follow-up CT is not that important or necessary." What do you think?

J Baugh: Yeah. Well that's a great question, because that is exactly what happened in this case.

Brian F. : Really?

J Baugh: The patient's wife gave a deposition during the pendency of the lawsuit, and she testified in her deposition that they didn't reschedule the appointment themselves after the physician's office had canceled it, because they didn't think the appointment was that important.
The fact the physician canceled the appointment and didn't reschedule it caused them to think that maybe the appointment wasn't that important, that maybe it was routine, that the patient was okay and that everything was all right. And unfortunately that was not the situation in this case.

Brian F. : You know, really it stands to reason too. You think you're going to this medical professional, they are the people that are in the know, and if it was that serious, or potentially a life-threatening type of issue, they're immediately going to reach out to me to reschedule. So the fact that they don't do that, I could see how somebody might even end up in that boat.

J Baugh: That's right. You know, a lot of people think that no news is good news.

Brian F. : That's exactly right.

J Baugh: So if they don't hear news from the physician's office that something needs to be rescheduled, or more testing need to be done, or some sort of follow-up is necessary, then they just assume that why bother coming back? It would just be routine, it wouldn't be something that I would have to do. So, like you said, they rely on the physician to do that, because they're the ones that are in the business of doing that.
Now, I do think that this type of situation brings another issue to light that I'd like to talk about for just a minute.

Brian F. : Okay, great.

J Baugh: And that question is, how should a physician communicate findings that are concerning with a patient? Now, a physician obviously doesn't want to unnecessarily scare a patient, but at the same time, the physician doesn't want to just gloss over an important finding.

Brian F. : Sure. That can be just as dangerous, can it?

J Baugh: That's a very delicate balance that the physician has to consider, how am I going to communicate this effectively with the patient? But you know, I wonder if the patient had been told more during the initial visits, when the physician said, "We need to schedule a follow-up," if the physician had said a little bit more at that first visit, then maybe the patient would've had a better understanding of the importance of the follow-up visit and not just say that that something is routine.

Brian F. : So maybe even, not necessarily scaring the patient with the severity, but stressing the importance of, "We can catch something on the front end, it's a lot easier to treat," things of that nature to at least give them a glimpse inside the process of why it's important.

J Baugh: That's right. I think it's important for the physician to not only tell the patient, "This is what we need to do," but to tell the patient, "This is why we need to do it."

Brian F. : Excellent point.

J Baugh: And if you tell the patient why you need to do something, then maybe that instills in them the understanding that this really is important, that I really need to come back and it's in my best interest that I do that.

Brian F. : For some people like me, I have to often understand the why, and that's what clicks for me, for me to remember it.

J Baugh: Absolutely.

Brian F. : So that is a great point. As we get toward the end of kind of wrapping up our discussion J, if you look back on this case in its totality and all of the complexities of it, what would you say are the main takeaways, maybe regarding the tracking and the communication? Because these are the things that you and I seem to keep coming back to is, is the tracking of the patient, and the rescheduling of the appointment, and the communication or a lack thereof with the patient. What would you give us as the main takeaways here?

J Baugh: Well, as far as the radiologist is concerned, I think he needs to be careful on how he dictates his findings in his report, and you ought to give some thought about the best way to communicate those findings to the physician who ordered the films.
We often see in cases where a plaintiff alleges that a radiologist either didn't read a film properly, or maybe the radiologist didn't do enough to communicate his findings to the ordering physician. Now, in this case, the plaintiff didn't allege the films were misread, but he did allege that the findings were too vague and maybe it didn't put the ENT physician on notice of how serious the findings were.

Brian F. : Got you.

J Baugh: And the plaintiff also said that the radiologist should have called the ENT physician because the findings were so-

Brian F. : [crosstalk 00:14:03].

J Baugh: And that's another allegation that we hear a lot, "Why didn't you just pick up the phone and call?"

Brian F. : And some of things are easy to see in hindsight, right?

J Baugh: That's exactly right. I mean, when you go through the day-to-day practice that a physician understands, they know the best way to communicate things to other physicians and the patients, and sometimes someone who's on the outside thinks that it's just very simple to pickup the phone and call, but we know the day-to-day demands of a physician's practice.

Brian F. : Of their time, yeah.

J Baugh: Absolutely.
Fortunately, in this case, the jury didn't agree with the plaintiff's allegations and they found in favor of the radiologist at trial. But those are a couple of things for a radiologist to consider.
Now, as far as the ENT physician is concerned, I think it's important for those physicians to think about the best way to communicate the importance of a follow-up visit. You want to convince the patient that the follow-up visit is not just simply routine, but that it's a very important visit that's necessary in the care of the patient, without unnecessarily scaring the patient. It's a very fine line that physicians have to walk between being informative without unnecessarily causing the patient to panic.

Brian F. : And you're right. I think that is very delicate to handle, and physicians can be fantastic at walking that fine line of being able to make sure they understand the importance versus making sure that they don't go home and hit the internet right away and go, "Oh no," you know, the world's worst scenario.

J Baugh: Absolutely. And then one last point would be that if a physician's office has a very unusual situation like we had here, where the physician had to cancel an entire week of appointments, it's important for management to take a step back, to review the processes that are in place, that work on a day-to-day basis and say, "Is there something that we should do maybe a little different in this situation that's so unusual?"

Brian F. : And I think that is a great point. You're kind of prepared for the norm. You're prepared for patients canceling an appointment, or something coming up at the last minute. Many of us have had a situation where a physician's office calls and says they're sick for the day, and they're not gonna be able to see you, or they've gotten tied up in an emergency case and are not going to be there, but that sets you back one day. That doesn't set you back an entire week. And I think that is something you don't prepare for. You don't have an action plan necessarily for that, unless you think about the possibility.

J Baugh: Yeah, that's right. You can't have an action plan in process for every scenario that's possible. Tracking plans are greats sure for day-to-day basis, but when you have something as unusual as this, take a step back and say, "Is there anything that we need to do differently?"

Brian F. : J, this has been very informative and I really appreciate all of your information. I'm certain our listeners are going to be able to gather a lot out of this as well. And I just tell you thanks for joining us today.

J Baugh: Well, thanks for having me. I enjoyed being with you.

Speaker 1: Thank you for listening to this episode of Your Practice Made Perfect with your host, Brian Fortenberry.
Listen to more episodes, subscribe to the podcast, and find show notes at SVMIC.com/podcast.
The contents of this podcast are intended for information purposes only and do not constitute legal advice. Policy holders are urged to consult with their personal attorney for legal advice, as specific legal requirements may vary from state to state and change over time. All names in the case have been changed to protect privacy.