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.
Very insightful comment, really appreciate it! I did not realize the difference in screening recommendation between first and second degree relatives with CRC (my grandfather died of colon cancer so especially relevant to me). You would think the defense would raise that objection but I'm assuming they thought the jury would be so sympathetic to the patient (mom with young kids, popular teacher in the community) that they figured it was best to settle.
Is there any good rule of thumb for what time frame differentiates sporadic (usually hemorrhoid) bleeding vs ongoing bleeding?
Typically hemorrhoids might bleed once a week or once a month, or twice a year - pretty variable. Very rarely we'd see someone (like someone who does hard physical labor or a weightlifter) who bleeds almost daily from hemorrhoids, but it's typically sporadic. "Daily" or bleeding most days, then needs a colonoscopy, regardless of the patient's age.
Second degrees don’t really factor in much, but if multiple second degree relatives then recommendation is to get screened with colonoscopy and not some other method like FIT testing. They don’t have zero input, but certainly much less. In reality many GIs may break from guidelines to be more aggressive with strong second degree family histories though.
No guidelines I’m aware of on timing of bleeding. But usually one day a week is enough to “reset” the clock.
Agree. I think a major point here is that there is a substantial difference between "finding a hemorrhoid on exam" and "definitively identifying a hemorrhoid as the source of ongoing rectal bleeding". Anatomically, everyone has hemorrhoids. And with our shitty diets (heh), poor bathroom habits, etc. it's not uncommon to have them be readily apparent on exam. Doesn't mean they're the source of bleeding, though.
In my mind, that's actually a diagnosis of exclusion. In other words, excluding other common causes of rectal bleeding...like cancer.
Exactly right. Everyone has hemorrhoids, so no way to tell if this was true bleeding source, unless you look further. I've had multiple patients who say "the bleeding is definitely my hemorrhoid doc, no doubt." Then I push them for colonoscopy... cancer.
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.
That's a pattern I see a lot in med mal cases... there are some criticisms that can be made, but even if the doctor had done something different, outcome probably wouldn't have changed. What's a typical time frame to go from bleeding polyp to malignancy?
There might be some data on it. Not sure. But gestalt would be months to a year from gross bleeding from a polyp to malignancy. Cases like this make me wish these cases had to be decided by a true jury of peers.
The lesion was almost certainly there in 2016. And not just a polyp, but likely something that was either high-grade dysplasia/CIS or early adenocarcinoma.
The oncogenic pathways for colon polyps are fairly well-studied. The time from polyps to adeno is long (10+ years). But the timing of early cancers to symptomatic detection is shorter (like 2-4 years).
From nascent polyp to cancer is long. From bleeding polyp to cancer is not 10 years. It CAN be years, but isn't always. This ambiguity, to me, means that I wouldn't have voted on that jury to say it was the thing that caused harm to the patient. Breach of standard of care? Yes, should've had a colonoscopy well in advance.
Which is why the people in 2010 aren't being sued. The evaluation in 2010 is reasonable to argue that it didn't necessarily cause harm. But pretty easy to understand how the missed diagnosis in 2016 changed things from "local rectal cancer" to "metastatic rectal cancer".
Which brings up another point. Part of the problem here is anchoring. She absolutely could have had bleeding hemorrhoids in 2010. However in 2016, it is wrong to simply chalk it up to bleeding hemorrhoids again without doing an appropriate workup. Sure, it could be bleeding hemorrhoids again. But it could also be a new malignancy.
Yes totally agree. I would maybe be doubtful of the utility of a colonoscopy in 2010. I would've done it without issue though. Definitely in 2016 should've been done.
Disagree. I'm a surgical oncologist. 2 years is definitely believable from "early rectal cancer" to "widely metastatic rectal cancer". The precursor lesion was almost certainly there in 2016.
As far as I could see (maybe missed it) we don't have info about staging in 2018. May not have been metastatic then or could have been minimally so. Without that info hard to say. But it's more believable to me that a rectal cancer would NOT be present for two years in the absence of bleeding. The fact that there was no continuous bleeding between 2016 & 2018 suggests it wasn't cancer at that point.
It's in the write up. Staging in 2018 had metastatic liver lesions. It's eminently reasonable to believe she went from local disease to metastatic disease in 2 years.
And there's no data for or against the issue of whether she continued to bleed for 2 years.id be amazed to find she didn't have intermittent bleeding in that time period.
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.
Its a philosophical conundrum because you can always keep looking for another cause, but in most people its futile. Knowing when to keep searching and when to stop is what separates the experts, but no one will ever be perfect.
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.
If they're young and its a first episode of bleeding (and no abdominal pain, Hgb and vitals reassuring), I don't usually CT but do give them a referral to see GI if bleeding becomes chronic. Lots of practice variation on this issue, I think.
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.
Very insightful comment, really appreciate it! I did not realize the difference in screening recommendation between first and second degree relatives with CRC (my grandfather died of colon cancer so especially relevant to me). You would think the defense would raise that objection but I'm assuming they thought the jury would be so sympathetic to the patient (mom with young kids, popular teacher in the community) that they figured it was best to settle.
Is there any good rule of thumb for what time frame differentiates sporadic (usually hemorrhoid) bleeding vs ongoing bleeding?
Typically hemorrhoids might bleed once a week or once a month, or twice a year - pretty variable. Very rarely we'd see someone (like someone who does hard physical labor or a weightlifter) who bleeds almost daily from hemorrhoids, but it's typically sporadic. "Daily" or bleeding most days, then needs a colonoscopy, regardless of the patient's age.
Second degrees don’t really factor in much, but if multiple second degree relatives then recommendation is to get screened with colonoscopy and not some other method like FIT testing. They don’t have zero input, but certainly much less. In reality many GIs may break from guidelines to be more aggressive with strong second degree family histories though.
No guidelines I’m aware of on timing of bleeding. But usually one day a week is enough to “reset” the clock.
Agree. I think a major point here is that there is a substantial difference between "finding a hemorrhoid on exam" and "definitively identifying a hemorrhoid as the source of ongoing rectal bleeding". Anatomically, everyone has hemorrhoids. And with our shitty diets (heh), poor bathroom habits, etc. it's not uncommon to have them be readily apparent on exam. Doesn't mean they're the source of bleeding, though.
In my mind, that's actually a diagnosis of exclusion. In other words, excluding other common causes of rectal bleeding...like cancer.
Exactly right. Everyone has hemorrhoids, so no way to tell if this was true bleeding source, unless you look further. I've had multiple patients who say "the bleeding is definitely my hemorrhoid doc, no doubt." Then I push them for colonoscopy... cancer.
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.
That's a pattern I see a lot in med mal cases... there are some criticisms that can be made, but even if the doctor had done something different, outcome probably wouldn't have changed. What's a typical time frame to go from bleeding polyp to malignancy?
There might be some data on it. Not sure. But gestalt would be months to a year from gross bleeding from a polyp to malignancy. Cases like this make me wish these cases had to be decided by a true jury of peers.
The lesion was almost certainly there in 2016. And not just a polyp, but likely something that was either high-grade dysplasia/CIS or early adenocarcinoma.
The oncogenic pathways for colon polyps are fairly well-studied. The time from polyps to adeno is long (10+ years). But the timing of early cancers to symptomatic detection is shorter (like 2-4 years).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9924026/
Thanks for posting a link to article.
Completely agree.
From nascent polyp to cancer is long. From bleeding polyp to cancer is not 10 years. It CAN be years, but isn't always. This ambiguity, to me, means that I wouldn't have voted on that jury to say it was the thing that caused harm to the patient. Breach of standard of care? Yes, should've had a colonoscopy well in advance.
Which is why the people in 2010 aren't being sued. The evaluation in 2010 is reasonable to argue that it didn't necessarily cause harm. But pretty easy to understand how the missed diagnosis in 2016 changed things from "local rectal cancer" to "metastatic rectal cancer".
Which brings up another point. Part of the problem here is anchoring. She absolutely could have had bleeding hemorrhoids in 2010. However in 2016, it is wrong to simply chalk it up to bleeding hemorrhoids again without doing an appropriate workup. Sure, it could be bleeding hemorrhoids again. But it could also be a new malignancy.
Yes totally agree. I would maybe be doubtful of the utility of a colonoscopy in 2010. I would've done it without issue though. Definitely in 2016 should've been done.
Disagree. I'm a surgical oncologist. 2 years is definitely believable from "early rectal cancer" to "widely metastatic rectal cancer". The precursor lesion was almost certainly there in 2016.
As far as I could see (maybe missed it) we don't have info about staging in 2018. May not have been metastatic then or could have been minimally so. Without that info hard to say. But it's more believable to me that a rectal cancer would NOT be present for two years in the absence of bleeding. The fact that there was no continuous bleeding between 2016 & 2018 suggests it wasn't cancer at that point.
Keep in mind don't need (visible) bleeding necessarily to have been either early ca or dysplastic lesion.
It's in the write up. Staging in 2018 had metastatic liver lesions. It's eminently reasonable to believe she went from local disease to metastatic disease in 2 years.
And there's no data for or against the issue of whether she continued to bleed for 2 years.id be amazed to find she didn't have intermittent bleeding in that time period.
Ahh yes I missed that. Yes if it was metastatic in 2018 then it was at least a worrisome polyp in 2016. You're right.
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.
Its a philosophical conundrum because you can always keep looking for another cause, but in most people its futile. Knowing when to keep searching and when to stop is what separates the experts, but no one will ever be perfect.
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.
If they're young and its a first episode of bleeding (and no abdominal pain, Hgb and vitals reassuring), I don't usually CT but do give them a referral to see GI if bleeding becomes chronic. Lots of practice variation on this issue, I think.
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.
You're doing the exact correct thing, absolutely.
When you say policy limit, what is the average policy limit across the board in your experience. 2-4 mil?
$1M per lawsuit is most common. I see 2-3M sometimes but feel like its pretty rare.