Legal Aspects Of Health Care Administration 11th Edition by George Pozgar

Exercise 10

Facts
Corley began experiencing low back pain on February 11, 1988. He sought medical treatment from Dr. Gremillion. Corley complained that he had been experiencing low back pain and abdominal discomfort for approximately 4 months. At Corley's request, Gremillion ordered x-rays of the lower spine, chest, kidneys, and gallbladder, as well as an upper gastrointestinal series. Gremillion, feeling that a specialist should see Corley, then gave him a written referral to a medical center for an orthopedic evaluation.
On March 2, 1988, Corley went to the medical center's emergency department with his wife. The Corleys presented admitting personnel with Corley's records from Gremillion, including x-rays and other test reports. Dr. Fuller, an emergency department physician, took a history from Corley and reviewed Gremillion's notes and the x-ray reports. He also conducted a routine physical examination and had x-rays made of Corley's lower back. Fuller's impression was that Corley was suffering from low back pain. Fuller continued Corley on the medication prescribed by Gremillion and made an appointment for him with the orthopedic clinic on March 16, 1988.
On that date, a fourth-year resident, Dr. Bridges, saw Corley in the orthopedic clinic. Bridges conducted a physical exam, which was normal, and started Corley on a conservative course of treatment for low back pain.
Dr. Mehta next saw Corley on April 20, 1988. Mehta's notes reflect that his physical exam of Corley was normal but that he felt that Corley had a posture problem and referred him to physical therapy for correction of his posture. The notes do not reflect whether Mehta reviewed any of Corley's previous medical records, x-rays, or reports.
On September 14, 1988, Corley was seen by a fourth-year surgical resident, Dr. White, who, during the course of the examination, ordered a CT scan of Corley's low back. Dr. Ellis, a radiologist at the medical center, interpreted the CT scan as showing arthritis consistent with fibrosis or spinal stenosis and possible edema of the right L5 nerve root, which, according to White, may or may not have been the cause of Corley's back pain. White did not review any of the previous medical records, x-rays, or reports. Corley's last visit to the medical center was September 21, 1988. On that date, White reviewed the results of the CT scan with Corley, continued him on an anti-inflammatory drug, and encouraged him to continue his back exercises.
On October 26, 1988, Corley, plagued by constant back pain and beginning to experience difficulty breathing, consulted Dr. Maxwell, a chiropractor, who did a full spinal x-ray that revealed a markedly diminished right lung area. Maxwell sent Corley to his father, also a chiropractor, who confirmed that there was a potential problem with Corley's right lung and recommended that he see a pulmonary specialist.
On October 31, 1988, Corley presented to Gremillion complaining of chest congestion and shortness of breath. Gremillion diagnosed him with bronchitis and implemented treatment. Corley returned to Gremillion on November 14, 1988, with complaints of shortness of breath and marked weight loss. Subsequent diagnostic testing confirmed the presence of a very large mass (cancer) in Corley's right chest. Prior to his death on January 23, 1990, Corley received radiation and chemotherapy treatment.
Corley's surviving spouse and son instituted a malpractice action seeking wrongful death and survival damages. The trial court rendered judgment in favor of the plaintiffs and against the medical center in the amount of $400,000. The defendants, the state, and the medical center appealed.
Issue
The primary issue on appeal is whether the trial court committed error in finding that the physicians at the medical center deviated from the applicable standard of care by failing to properly diagnose Corley's condition, a large cancerous mass in his mediastinum, during the course of their treatment of his low back pain.
Finding
The physicians at the medical center fell below the standard of care when they failed to properly diagnose Corley's condition.
Reason
The evidence was in Gremillion's x-rays and medical report when Corley first arrived at the medical center. Simply put, these physicians failed to see what they should have seen. When Corley did not respond to conservative treatment, there had to be another explanation for his low back pain. The physicians ignored this and did not expand their inquiry, which they should have done under a differential diagnosis assessment. For this, Corley was deprived of a significant chance of survival. A physician is required to take a "thorough" history based on a patient's presenting signs and symptoms. If the findings from the medical history and physical exam support a diagnosis, one should be made and treatment instituted. When, in treating a patient, a diagnosis cannot be made, at that time, a differential diagnosis should be made, which includes all reasonable, plausible, and foreseeable causes for the signs and symptoms noted in the patient. After forming a differential diagnosis, it is the physician's duty to rule out all imminent, serious, and life-threatening causes for the signs and symptoms. Failure to eliminate these causes can subject a patient to a foreseeable risk of harm and would further constitute a breach of the applicable standards of care.
Why did the appellate court find that the trial court had not erred in finding that the physicians deviated from the applicable standard of care in their diagnosis and treatment of Corley?