Who worries about physician behavior? Who is ultimately responsible?

There is a true story of a 30 yo woman who has a history of rheumatoid arthritis, and who developed unusual eye symptoms. She went to a physician who referred her to a neurologist (both were “independent medical practitioners”). The neurologist diagnosed Myasthenia Gravis and ordered a CT scan of the thymus. When there was a report of an unusual density in the thymus, a thymectomy was recommended. The patient was told that the alternative therapy was potentially long term corticosteroids. She sought, and received, a second opinion from a nearby Academic Medical Center by a neurologist, specializing in neuromuscular diseases and especially in Myasthenia Gravis. The specialist at the AMC could not confirm the diagnosis of MG. The young woman then went to Mayo clinic, where again the diagnosis of MG was not confirmed and the diagnosis of thymus tumor was also unable to be verified. To date there is no clear diagnosis of this woman’s problem, but neither the diagnosis of Myasthenia Gravis, or of Thymus tumor was confirmed.

Questions:

1. The AMA has long had a prohibition on disagreements with prior diagnoses by other physicians dating to a 1903 code of ethics. When is it ethical to discuss a disagreement in a diagnosis with a patient?
2. What is the obligation of a hospital/system, if the surgery was done?
   1. The OR is clean, anesthetic gasses and drugs are appropriately labeled and dispensed.
   2. The Surgeon removes Thymus and there are no complications from the surgery.
   3. The Pathologist (a hospital employee in most instances) reports a non-diseased thymus.
   4. The Patient’s symptoms remain stable.
3. If we assume A – D then does the hospital have an obligation to question the appropriateness of the therapy in a case like this?
4. The referring physician and the neurologist believe that they have performed a valuable service to the patient. Did they?
   Is there a mandatory case review of a specific number of cases and what is
   the censure if reviews are not attended?
5. What is the responsibility of the payer?
   1. The treatment was not for a diagnosis that was confirmed.
   2. There will be follow up visits.
   3. How can we incentivize doctors to make time to “go to the literature” when they don’t know the answer to a patient problem from their experience base?
   4. How can we incentivize doctors to find the person who may be best able to help this patient, without destroying the physician patient relationship?
6. What is the responsibility of the Medical Society/State Licensing Board?

This was not quite “Malpractice”, but it wasn’t good medical practice. There are probably no “right” answers to most of these questions. They may, however, be a place to start.

I would encourage you, the reader, to comment as you see fit.