"In the OSCE exam, there maybe a discussion with the examiner on a medicolegal case. This is a case of "While I am here" which we see quite a bit in General Practice. Although, it is about a patient presented to a dermatologist, the general principles still apply. Understanding the principles discussed in this case will help you to structure your future discussion about medicolegal cases in the exam." Dr Vin.
A 42 year old woman presented to her dermatologist for laser treatment of facial hair. While there she asked the Dermatologist to review a number of multiple pigmented lesions on her back. Several pigmented lesions had been previously removed from her back with all reported as normal, but she had noticed an itchy lump at the site of the most recent excision which had been performed 12 months earlier. She had hypertrophic scars on her abdomen following past surgery and the dermatologist thought the itchy lump on her back was another hypertrophic scar. He offered a steroid injection but the patient decided to put up with the itch.
A plan of treatment was arranged for the facial hair. The dermatologist also said that he would obtain the histology results of earlier mole removals from the patient’s GP and review the lesions on her back when she returned after the course of laser treatment.
The patient did not attend for review as requested. When contacted by the practice nurse she expressed dissatisfaction at the laser treatment and said she had no intention of returning.
The patient’s GP forwarded the requested information but said that the last mole had been removed by a doctor in another practice and she did not have that pathology result. The available results were reviewed and nothing untoward noted.
No further inquiry was made regarding the histology of the last mole removed.
A year later the patient presented to her GP with a lump in her axilla. A biopsy was taken and reported as malignant melanoma and the primary site was found to be the hypertrophic scar at the site of the last mole excision. The original report was located and the pathologists had stated in it that the lesion was difficult to classify but on balance was thought to be benign. Close monitoring had been recommended.
The GP who performed that excision was no longer in practice and his records could not be located. The patient denied ever being told of the need for regular review or doubt that the lesion was benign.
The patient sued the dermatologist for failing to diagnose the recurrent melanoma and the GP who had excised it for failing to act on the pathology report.
Expert medical opinion was obtained which said the dermatologist’s diagnosis of a hypertrophic scar while ultimately shown to be incorrect was reasonably based on the facts available to the dermatologist at the time. However there was a risk he would be found to have failed in his duty of care by not following up the pathology result on the lesion that was removed from the site of the scarring.
The original pathology was reviewed and the conclusion of the experts was that the diagnosis and advice contained in the pathology report was appropriate.
The GP who had excised the last mole clearly failed to act on the histology report.
This was essentially a ‘while I’m here’ patient. She attended the dermatologist for laser treatment for facial hair but asked for a mole survey as well.
How did it happen?
The focus of the dermatologist’s attention was on the laser hair removal program and the mole survey and review of the lumpy scar were quite secondary. While the lack of the pathology report on the last mole was noted, the dermatologist took no further steps to find it. The GP who removed that mole and did receive the report on it failed to act on the pathologist’s concern and apparently did not convey that uncertainty to the patient and recommend close follow up.
How could it have been prevented?
‘While I’m here’ issues are often mentioned towards the end of the consultation, after the primary reason for attendance has been dealt with.
This can lead to them being given short shrift, as the doctor is ready to move onto the next patient. One way to avoid this is to ask, after the threshold question ‘What brought you to see me today?’ is ‘Was there anything else you wanted me to deal with?’ That doesn’t commit you to dealing with those other issues at that consultation, but if early in the consultation you elicit everything that is on the patient’s agenda, you can then negotiate what you can reasonably deal with at that visit and what should be deferred to a later time.
The principal issue in this case was related to the GP who removed the last mole and received the histology report on it. It appears he only read the headline which had the word benign in it. He did not read the rest of the report which indicated a level of uncertainty about the diagnosis and recommended early and frequent review of the excision site.
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