Lump in the Throat
Posted on 20. Aug, 2009 in Case Reports
Case Synopsis
It’s Just Reflux
Having a long time physician tends to be a good thing. But this may not always be the case. Way back in 1979, Gerald* was having difficulty urinating, constipation, among other medical ailments.
One particular problem that Gerald brought up to Dr. Binkley* was that he was having “heartburn” and stomach pain. 
Sometimes he would choke, cough, and experience chest pain. He was diagnosed with “reflux esophagitis”. Despite ongoing complaints, no diagnostic studies were performed to find the cause of these symptoms until nearly 8 years later in 1987.
Let the Tests Begin
In March of 1987, Dr. Binkley ordered some x-rays which showed a mass in his esophagus. Dr. Binkley’s opinion at the time was that it was probably benign. Nothing to worry about–he would perform another esophagram in two months…except that this was never done.
A year later, Gerald came back to the office with more heartburn, morning headaches, difficulty sleeping and nausea. Dr. Binkley immediately ordered a second esophagram and felt that the result looked just like the one before.
For three more years Gerald continued to complain about a variety of symptoms. Finally in April of 1991, another esophagram was performed. This time, the esophagus appeared much more thickened. And as before, Dr. Binkley did not follow up on the findings of the study.
Ignorance is Not Bliss
Over a year later in August 1992, Gerald visited Dr. Binkley again. He had lost 13 pounds and was having nightly fevers. Over the next several days, Gerald’s condition worsened. He had poor appetite, soreness in the chest, and his belly was distended.
In early September 1992, Dr. Binkley hospitalized Gerald so an array of tests could be done, which revealed extensive cancer of the esophagus that had spread throughout his body.
Case Outcome
Gerald died two months later.
Dr. Binkley received a public letter of reprimand and was fined $2500 for costs incurred for the investigation. Because his license was already inactive, it could not be revoked.
Analysis by Florence
I think this is a difficult story for most of us, myself included. When we find a primary doctor (whether by referral, or the doctor is the only one in town, or great recommendations from our friends, or simply having grown up with the doctor) we slowly develop a special relationship with them. After all, from minor problems such as the common cold to larger illnesses as we get older, we learn to trust them. Their loving hands have cured us many times. Very seldom in my own experience would I think of questioning what my doctor would say—she knows best.
Just like it was, during my teenage years, so hard for me to accept that my father and mother weren’t flawless, we have a hard time accepting that our doctors could have problems, too. The bonds we develop through the years makes us trusting and willing to be blinded by “she’s so caring”. Isn’t that what society leans toward? The caring, gentle doctor, not the ruthless yet educated one. It’s such a difficult line to balance.
Gerald came in over and over again to see Dr. Binkley. Over and over again, Dr. Binkley performed tests and assured Gerald there was nothing wrong. Gerald wanted to believe the doctor, and because of their special relationship, he did. Many of us would do the same. Unfortunately, in this case, the trust was not deserved.
In the beginning of the case, it seems that Dr. Binkley did his duty by taking an esophagram whenever he saw the patient (for some reason one was not done within 2 months of the first one, but we can’t say for sure who’s fault that is). However, Dr. Binkley felt that there was no difference between the first and second esophagrams, and so did nothing. The actions of the doctor still do not seem to be egregious yet at that stage. It was only after not following up on the third esophagram do we finally realize the incompetency of the doctor. There does not seem to be any reason why follow-up not was done, or why another doctor was not consulted.
This case shows the importance of a second opinion. It is most likely that the cancer could have been caught had either the patient or doctor sought the opinion of another doctor. I’m surprised that Dr. Binkley did not even bother sending the results to a specialist to consult. He did absolutely nothing until it was much too late. Consulting with other doctors, especially specialists, should be something of the norm and done frequently.
Normally, bad ethics should not be confused with incompetency. Doctors may mean the best, but perform badly. However, in this case, the failure is so blatant and obvious that it is definitely pushing the boundaries between ethics and aptitude. It seems the punishment received by the doctor was rather light, although there was not much else the board could have done.
| Score |
|---|
| 6.8 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 6 | 8 | 5 | 5 |
Response by Marc
Flo, I couldn’t agree with you more. I think you hit it head on that Gerald came in over and over again to see the doctor and continued to trust him. But at some point, a red flag definitely should have been raised, “This is strange, I’m feeling worse! Let me get a second opinion!”
And while I agree that some doctors have lost their competency, there may be some system issues in this case as well. Often times, a test is ordered, the patient leaves the office, and everything is forgotten. What system is in place to trigger the review of results? Does the doctor wait until the lab sends a report back? Are the results compared to the previous chart records?
After the first esophgram, Dr. Binkley said he’d perform another in 2 months. How is this remembered? The chart doesn’t just pop up in 2 months to remind him. Most likely, he told Gerald to come back in 2 months, at which point he would review the chart and realize he needs to repeat the test. For a doctor, relying on patients to remind you is not the best method.
Also, in his likely busy clinic, Dr. Binkley may not have fully reviewed Gerald’s chart for each visit. Often times, a doctor would walk in and ask what’s going on? “Oh heartburn, try this…” Next visit, “oh more heartburn, try this…” It’s not hard to see how this would lead to missed diagnoses.
So the two take home messages for the doctors I would emphasize are: 1) make sure there is a system in place to remind you to check a result or order a test—don’t just rely on the patient; and 2) review the chart fully with each visit so repeated oversight does not happen.
| Score |
|---|
| 5.6 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 4 | 7 | 3 | 4 |
Response by Lyssa
Sure, we should seek second opinions, but should we not be able to trust our doctors? When to draw the line to get a second opinion is extremely difficult.
In my mind, in this case Dr. Binkley should have achieved the correct diagnosis, without need for a second opinion. Unnecessary second opinions only increase the cost of healthcare and allow incompetence to go unpunished or even rewarded. Constant referral seems to be the norm these days. This might work for those with unlimited, deep pockets, but not for the general population. This seems costly and impractical.
| Score |
|---|
| 7 |
| Damage | Anger | Ineptitude | Shock | Ethics |
|---|---|---|---|---|
| 10 | 7 | 8 | 4 | 6 |
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Cat
Aug 21st, 2009
This one hits a personal note with me. My grandma had developed a horrible cough and the doctors(for three years) just kept telling her she had pneumonia and that because she was a smoker she was at a higher risk to keep getting it. She finally ended up in the emergency room coughing up blood and so bad she wasn’t able to catch her breath. When they ran tests, they found out she had lung cancer. She died three months later.
She didn’t have the best health care and getting a second opinion would’ve cost her money out of pocket that she couldn’t afford. Whenever she would go in,the antibiotics would work for a while so in her opinion she had no reason to not believe what her doctor told her.
I understand doctors are much busier than before and that people should be more pro-active about their health, but we are taught from an early age that these people go to school for all those years so they can diagnosis our symptoms. That because they are the professionals they know what they are talking about at all times. There’s also the piece of not wanting to make your primary doctor upset by questioning their opinion/diagnosis. I have met some doctors who were extremely upset when their patient asked for a second opinion. I know I’ve trusted previous doctors about a diagnosis only to have it be wrong, thankfully none of mine have been fatal.
I really think more could/should have been done on the doctor’s part.