Originally published September 2013
A patient who repeatedly returns with unresolved complaints, or with symptoms that worsen or do not respond to treatment as expected, may signal a serious unsuspected medical condition. These ongoing health issues can also increase medico-legal risk.
The CMPA reviewed 452 medico-legal cases that closed between 2007 and 2012 involving patients with repeat visits. These cases included a wide range of serious diagnoses. Family physicians, emergency physicians, surgeons, and medical specialists were all involved.
Patients presented with clinical conditions ranging from the common to the unusual: extremity and spinal fractures after motor vehicle accidents or falls, appendicitis, myocardial infarction, cancer, abdominal aortic rupture, subarachnoid hemorrhage and stroke, sepsis, endocarditis, necrotizing fasciitis, and others.
Experienced physicians will recognize these conditions can be very difficult to diagnose during a single patient encounter. These cases also share a common theme of return visits without reassessment of the diagnosis. Often these patients' unresolved health issues are viewed as treatment failures rather than as diagnostic failures.
Revisit the history and physical examination
Delays in diagnosis can be related to an atypical presentation or to the variable progression of the disease, and many conditions must progress to where symptoms and signs suggest the diagnosis or the need for further investigation. Because symptoms can evolve over time, careful history-taking and documentation are crucial.
When a patient returns for a medical visit, it is important that the physician be vigilant in considering if the patient's overall appearance, vital signs, and physical examination raise any red flags. Failure to do vital signs when appropriate, continuing abnormalities, or worsening vital signs, figure prominently in many medico-legal cases. Experienced clinicians recognize that abnormal vital signs can signal more serious illnesses, but also that normal vital signs do not necessarily rule these out.
The review of cases identified the following high-risk situations:
multiple visits from patients with unresolved concerns over a short period of time
patients' condition not following the natural course of presumed illness or patients not responding to treatment as expected
patients consulting with multiple physicians for the same ongoing concern
In these situations, it is good practice to stop and think: is the presumptive diagnosis correct?
Reconsider the differential diagnosis
Formulating a differential diagnosis — that is, developing a reasonable list of the possible conditions that could produce a patient's symptoms and signs — is central to clinical reasoning. It enables appropriate testing to rule out the possibilities and arrive at a final diagnosis.
However, when a patient is not improving as expected or the diagnosis is unclear, the differential diagnosis may need to be expanded and further investigations or consultations may be required. It is often important to repeat the physical examination and reassess vital signs.
A patient's pre-existing or past medical conditions may narrow the physician's differential diagnosis inappropriately. This phenomenon was seen often in cases involving return visits. For example, an older male visited his family physician several times over 6 months complaining of shortness of breath. The physician treated the patient's symptoms as an exacerbation of his asthma and allergies. In fact, he had lung cancer. A chest X-ray, if done earlier in this case, likely would have revealed the diagnosis.
Recent surgery was a common patient characteristic in cases. A number involved physicians who failed to recognize that a patient's symptoms were a complication of surgery. As well, recent diagnoses of other patients can also influence a physician's diagnostic acumen. This is known as "availability bias." Recent or vivid diagnoses are more easily remembered and therefore are overemphasized in the differential diagnosis.
Often physicians inherit or are influenced by the diagnostic reasoning of others who have previously examined the patient. Overreliance on an earlier presumptive diagnosis can lead to diagnostic momentum or the "bandwagon effect." What should have started as a diagnostic possibility becomes a diagnostic label and other possibilities are not considered. It is wise for physicians to rethink their initial diagnosis or those made by others (even more senior or specialty trained colleagues) when symptoms are not resolved as expected.
Like physicians, patients can anchor1 on a recent event or past diagnosis to explain their symptoms. They may self-diagnose or use medical terms incorrectly. This may prompt inappropriate investigations and treatments.
As well, diagnosis can be complicated when the patient has more than one complaint or condition. The use of prescription medication can also affect diagnosis, as the symptoms of a condition can be incorrectly attributed to the side effects of a medication. One case illustrates both of these situations. A young woman was already being treated with an NSAID for musculoskeletal pain when she presented to her family physician with complaints of abdominal pain. Her symptoms were attributed first to a side effect of the medication and then to a urinary tract infection when urinalysis found leukocytes. Experts felt a more thorough assessment might have identified the final diagnosis of appendicitis earlier.
When patients do not comply with treatment plans, scheduled investigations, or follow-up appointments, physicians can feel frustrated. However, many factors can contribute to non-adherence, including communication issues between physicians and patients, patients' comfort-level with the treatment plan or even their ability to afford a treatment. Unresolved health complaints by non-adherent patients can also signal serious conditions and may require additional effort.
On repeat visits patients may be frustrated, upset, or angry. It is important to avoid reacting similarly and instead listen to and address the concerns of patients and their families in a professional and direct manner. Their perspective is crucial in bringing forward new information. Patient anger may provoke a similar response in the physician making it difficult to remain objective. Consulting with a colleague may be helpful and bring a fresh view to the problem. Following an unexpected and serious clinical outcome, perceptions by patients or families that their concerns had been minimized may result in a complaint, legal action, or both. If there is not enough time to address multiple problems during a visit, this should be documented in the patient record and a follow-up appointment arranged.
Seek consultation if necessary
Consider the need for consultation or a second opinion with a colleague to confirm the existing diagnosis, whether a different diagnostic path needs to be explored, or if further investigations and other treatments are indicated. As part of a culture of safety, colleagues should welcome consultations both as an opportunity to assist with patient care and also to educate.
In one case, both a family physician and an orthopaedic surgeon did not recognize signs of vascular compromise in a patient with a foot wound that would not heal. Experts felt that the patient's amputation below the knee might have been avoided if a vascular specialist had been consulted earlier.
Provide discharge instructions
At the end of each visit, the physician should confirm that the patient understands the rationale for the recommended investigations or treatments, the presumptive diagnosis as well as the next steps for follow-up and what, if any, symptoms or signs to watch for. The physician should also explain whether or not the diagnosis has been determined, as this can help to manage expectations.
The timing of follow-up is important and should be tailored to the patient's symptoms and the progression of the disease. Continuity of care can be compromised when more than one provider is involved in a patient's care. This underlines the importance of clear communication between providers and across settings. A conversation with the patient's primary care or specialist physician may serve to both expedite and improve care.
Careful review of earlier entries in the record can either support the presumptive diagnosis or reveal clues that point to another condition.
Documentation of return visits should include any new information and physical findings including vital signs, as appropriate. The physician's notes should convey the rationale for continued treatment or, alternatively, reflect a new differential diagnosis with reference to any new testing required. The physician should also verify that no test results or imaging reports are outstanding. A delay in the interpretation or communication of results was a factor in a number of cases.
Missing or incomplete documentation can impede patient care and defense of the care, since inadequate records may convey a poor image of the physician's competence. Documentation issues were noted in a number of the cases reviewed.
Managing medico-legal risk
Physicians should consider the following risk management actions, which are based on expert opinions in the cases involving return visits:
Taking the time to pause and reflect on the differential diagnosis, being careful to consider possibilities that may be life-threatening.
Before establishing a diagnosis, reading all key elements of the patient's medical record including earlier entries, test results, and consult reports.
Using algorithms or clinical practice guidelines to assist clinical judgment in determining the need for further testing.
Creating a process to facilitate the review and follow-up of test results.
Being careful not to rely primarily on a colleague's earlier diagnostic impression when assessing a patient.
Being careful to keep an open mind when patients' explain the source of their symptoms.
Re-evaluating the diagnostic assumption and repeating the physical examination with vital signs, when the patient returns with the same or worsening symptoms.
Reflecting on whether cognitive biases such as anchoring or diagnostic momentum are influencing the ability to arrive at a final diagnosis.
Recognize that patients may be frustrated or angry, and so effective communication will be important to obtain new information. Consulting a colleague may be helpful.
Ensuring clear written and verbal instructions are provided to patients or their families.
Ensuring documentation reflects a thorough assessment, history taking, and the rationale for the differential diagnosis.
Documenting discharge instructions and relevant discussions.
The CMPA's Good Practices Guide provides comprehensive information on the most common cognitive biases and strategies for dealing with them. Available at: /serve/docs/ela/goodpracticesguide/pages/human_factors/Cognitive_biases/common_cognitive_biases-e.html