My post entitled “Who is at fault if a patient doesn’t follow up?” from August was well received. There were many comments on Twitter.

Here is some follow-up on following up.

A surgeon saw a new patient with flank pain. He had undergone an appendectomy a few years before by another surgeon at another hospital. He said that the surgeon told him the pathology report was “fine.”

He had a non-specific physical examination.

A CT scan showed a possible ureteral stone. A urologist was consulted, saw the patient, and said there was no stone.

The patient called the surgeon who told the patient to come back to her office to discuss further work-up. He did not keep the appointment. The surgeon made two more phone calls urging the patient to return and documented them in her office records. The patient was also called by the urologist, a consultant gastroenterologist, and his family doctor. He never followed up with any physician.

Two years later he presented to the ED with a small bowel obstruction. At surgery, carcinomatosis from his ruptured mucinous carcinoma of the appendix was found.

The CT scan from the initial surgeon office visit was re-reviewed and still showed no evidence of a tumor. The original pathology report said “mucinous tumor [not cancer] of the appendix.

Everyone except the surgeon who had done the appendectomy and the pathologist was sued. They escaped because of the statute of limitations.

The insurance companies advised all of the doctors to settle, which they did.

So much for documenting your attempts to have the patient seen.

Two of my Twitter followers from Australia sent me a link to a case that illustrates that patients in that country are somewhat responsible for their fate.

Briefly, it concerned a man who needed a Q fever vaccination for work. A skin test for Q fever was negative, but serology was weakly positive. An infectious disease specialist recommended that vaccination not be done. The patient was told to return in a month for a repeat serology. He failed to do so and contracted Q fever about 4 years later.

The patient sued. A judge ruled in favor of the physician saying the patient “understood the advice he was given by [the doctor] that he was low positive, that he needed further testing and that he could not be immunized. There was nothing in [the patient’s] presentation in court or within his evidence that suggested he did not comprehend what was said to him by [the doctor]. He denied being told to return by [the doctor]. I reject his account for the reasons already mentioned.”

This last one is hard to believe.

A brief “Viewpoint” article in JAMA from May of 2013 tells of the discovery of a new disease. It is called “Medication Nonadherence,” and it has six different phenotypes.

They are as follows: “(1) the patient does not understand the relevance of medication adherence to continued health and wellbeing; (2) the patient has concluded the benefits of taking medications do not outweigh the costs; (3) the complexity of medication management exceeds the information processing capacity of the patient; (4) the patient is not sufficiently vigilant; (5) the patient holds inaccurate, irrational, or conflicting normative beliefs about medications; and (6) the patient does not perceive medication to have therapeutic efficacy.”

I had trouble getting past the above portion of the paper.

However, the authors advocate screening all patients for this malady and treating it when found. They say, “Each medication nonadherence phenotype requires different diagnostic tools and treatments in the same way that subtypes of a medical condition, such as heart failure (diastolic vs systolic), require them.”

I thank God I am no longer in practice.

Skeptical Scalpel is a recently retired surgeon and was a surgical department chairman and residency program director for many years. He is board-certified in general surgery and a surgical sub-specialty and has re-certified in both several times. For the last three years, he has been blogging at SkepticalScalpel.blogspot.com and tweeting as @SkepticScalpel. His blog averages over 1000 page views per day, and he has over 6800 followers on Twitter.