As a gastroenterologist practicing for many years, I do not agree with all points made by the Medmal reviewer or the expert surgeon. First of all, the "family history" of a grandparent with CRC (colorectal ca) is irrelevant in terms of risk, and therefore such a family history is not included as a risk in any of our practice guidelines, including from the ACG, AGA, etc. The FH of the father may.... be relevant, but especially if this tumor found was related to Lynch syndrome. The overwhelming issue with this case, which the surgeon reviewer didn't point out, was that anyone, even a young person, with ongoing bleeding (as opposed to very sporadic bleeding) usually does not have hemorrhoids as the diagnosis. Hemorrhoids bleed only intermittently in the vast majority of cases; and even though CRC was a less likely diagnosis in this pt due to her age, we often find some other cause of chronic bleeding, like a Juvenile polyp, or ulcerative colitis or proctitis, in such a patient. Thus, I agree with the assessment that there was a breach, just not fully with the reasoning noted.
I (a gastroenterologist) doubt that a bleeding polyp in May 2016 would take 2 years and 3 months to become malignant. The bleeding in 2016 likely was the hemorrhoid and nothing more. That being said, this patient should definitely have had a colonoscopy just for having that many bleeding episodes overall. So below the standard of care? Yes. The source of injury to the patient? I very much doubt it.
I think this shows two issues. One; the easiest way to miss something is to find something else. You can't find alternative causes if you don't look for them. Two; I agree that the malignancy might not have been there earlier, it becomes Schrodingers tumor. You can't in hindsight prove it wasn't.
Maybe this is an ED doc's sensitivity to that fact that we only see a snapshot, but you gotta close the loop. Back in the day when CLIA wasn't interpreted to prevent us from POC heme testing, we worried that even seeing a hemorrhoid actively bleeding did NOT mean that it was the exclusive source of a + test. We would say, "You need F/U after the 'roid heals, to make sure there's nothing coming from further up." Time is one of parameters more easily used by office based physicians. On the other hand, if the plaintiff's expert is passing scopes as aggressively as he suggests is SOC, I can imagine an insurer and/or billing fraud police asking questions. Hugh Hill, MD, JD
As an ED physician, I am not sufficiently knowledgeable of all the nuisances, but a CRS should have a healthy skepticism for attributing reoccurring rectal bleeding to hemorrhoids. I certainly see a number of patients with rectal bleeding in the ED and unless they give me a great history and I find an obvious fissure, friable hemorrhoid on exam, etc, they usually get a CT scan (while not an endoscopy, it can find much of any worrisome pathology I need to uncover). So while I am loath to cast blame in the vast majority of these cases, this one would likely not play out well in court. Always better to be lucky than smart. It’s not fair or morally correct, but too often true.
ED perspective: there's been increasing evidence of younger people developing CRC. I never assume hemorrhoids for hematochezia discharges. I advise all patients, young and old, that a gastroenterologist must evaluate them to determine their risk and if further evaluation is needed. I say this regardless of finding hemorrhoids or not (you can have hemorrhoids and CRC). In the meantime I treat their hemorrhoids if present and tell them to follow up with GI regardless. This is the only approach I take as an ED doc and I always sleep well. Perhaps the GI doctors hate me. Perhaps they love me. They have the expertise to fully risk stratify folks. I'm not gonna do that as an ED doc.
As a gastroenterologist practicing for many years, I do not agree with all points made by the Medmal reviewer or the expert surgeon. First of all, the "family history" of a grandparent with CRC (colorectal ca) is irrelevant in terms of risk, and therefore such a family history is not included as a risk in any of our practice guidelines, including from the ACG, AGA, etc. The FH of the father may.... be relevant, but especially if this tumor found was related to Lynch syndrome. The overwhelming issue with this case, which the surgeon reviewer didn't point out, was that anyone, even a young person, with ongoing bleeding (as opposed to very sporadic bleeding) usually does not have hemorrhoids as the diagnosis. Hemorrhoids bleed only intermittently in the vast majority of cases; and even though CRC was a less likely diagnosis in this pt due to her age, we often find some other cause of chronic bleeding, like a Juvenile polyp, or ulcerative colitis or proctitis, in such a patient. Thus, I agree with the assessment that there was a breach, just not fully with the reasoning noted.
I (a gastroenterologist) doubt that a bleeding polyp in May 2016 would take 2 years and 3 months to become malignant. The bleeding in 2016 likely was the hemorrhoid and nothing more. That being said, this patient should definitely have had a colonoscopy just for having that many bleeding episodes overall. So below the standard of care? Yes. The source of injury to the patient? I very much doubt it.
I think this shows two issues. One; the easiest way to miss something is to find something else. You can't find alternative causes if you don't look for them. Two; I agree that the malignancy might not have been there earlier, it becomes Schrodingers tumor. You can't in hindsight prove it wasn't.
Ongoing Rectal Bleeding = Colonoscopy, aggressive yes, but I think that is the standard of care today
Maybe this is an ED doc's sensitivity to that fact that we only see a snapshot, but you gotta close the loop. Back in the day when CLIA wasn't interpreted to prevent us from POC heme testing, we worried that even seeing a hemorrhoid actively bleeding did NOT mean that it was the exclusive source of a + test. We would say, "You need F/U after the 'roid heals, to make sure there's nothing coming from further up." Time is one of parameters more easily used by office based physicians. On the other hand, if the plaintiff's expert is passing scopes as aggressively as he suggests is SOC, I can imagine an insurer and/or billing fraud police asking questions. Hugh Hill, MD, JD
As an ED physician, I am not sufficiently knowledgeable of all the nuisances, but a CRS should have a healthy skepticism for attributing reoccurring rectal bleeding to hemorrhoids. I certainly see a number of patients with rectal bleeding in the ED and unless they give me a great history and I find an obvious fissure, friable hemorrhoid on exam, etc, they usually get a CT scan (while not an endoscopy, it can find much of any worrisome pathology I need to uncover). So while I am loath to cast blame in the vast majority of these cases, this one would likely not play out well in court. Always better to be lucky than smart. It’s not fair or morally correct, but too often true.
ED perspective: there's been increasing evidence of younger people developing CRC. I never assume hemorrhoids for hematochezia discharges. I advise all patients, young and old, that a gastroenterologist must evaluate them to determine their risk and if further evaluation is needed. I say this regardless of finding hemorrhoids or not (you can have hemorrhoids and CRC). In the meantime I treat their hemorrhoids if present and tell them to follow up with GI regardless. This is the only approach I take as an ED doc and I always sleep well. Perhaps the GI doctors hate me. Perhaps they love me. They have the expertise to fully risk stratify folks. I'm not gonna do that as an ED doc.
When you say policy limit, what is the average policy limit across the board in your experience. 2-4 mil?