Guide for the management of breast lumps: Litigious aspects

As members of the medical profession we should be indebted to Mahoney and his collaborators for having formulated the excellent concise guide for the primary physician on managing breast lumps, published in this journal (Can J Surg 1998;41[6]:476-7). Once guidelines are published (in this area for example the "Clinical practice guidelines for the care and treatment of breast cancer" CMJ 1998;158[3 Suppl]), they tend to become the expected standard of care, even though, by definition, they are just guidelines. Although the target audience for this guide is the family physician, it is also of value to the general surgeon.

It is not uncommon to see examples of mismanagement of breast problems by general surgeons who disregard the recommendations set out by Mahoney and colleagues. The fallout may be a disaster for both surgeon and patient, particularly if the case ends up in the judicial system.

Loutfi's comment in "Quill on Scalpel" (Can J Surg 1998;41[6]:421), in which he admonishes us to listen to the patient seems so obvious, but we sometimes dismiss the patient's comments. The patient knows her own body and can often sense a problem. A woman doesn't go to her doctor because she thinks she has felt a benign lump or thickening. Loutfi wisely states that if you can't feel the lump that concerns your patient ask her to find it for you.

Experience has shown me that physicians who are involved in lawsuits keep abysmally poor office notes. A reference to what the patient is describing as a breast lump or thickening may be covered in the chart in a line or two, about the same amount of space as is given to someone complaining of a head cold. A proper history (listening to the patient) and a recording of proper clinical breast examination is usually nonexistent is such cases. I am always impressed at how well the doctor describes the breast examination while giving the description at Discovery. This is after the fact and merely demonstrates to the lawver for the plaintiff what the physician should have done. Keep accurate records and make a rough diagram with appropriate remarks - for example, the size and location of the questionable area and its physical characteristics. If you consider that what you are feeling is not significant, that is, not suggestive of malignancy, document why you don't think it is abnormal.

I recently reviewed a case in which the family physician attributed a breast thickening in a 40-year-old woman that did not regress after several months and had no counterpart in any other area of either breast as being due to normal cyclical change. The physician never once recorded a menstrual history or whether the woman was taking an oral contraceptive! I also note in these substandard charts (the only ones I get to see) that a lymph-node examination is almost never mentioned. After taking a proper history and doing an appropriate clinical breast examination, and diagnostic mammography and ultrasonography where indicated, if doubt remains in the mind of the primary care physician or the patient, the physician should have the good sense to refer the patient to a general surgeon. Even smaller communities (certainly those in southern Ontario) have such resources readily available.

These are the 1990s, the information age, where all kinds of information is available at the click of a mouse. I am constantly amazed at the quality and amount of information that is available to everyone on the Internet. In cases of alleged substandard care that are referred to the Complaints Committee of the provincial College of Physicians and Surgeons or that proceed to litigation, the patients and their families are well informed about how a breast lump should be managed and what constitutes the expected standard of care. The very act of keeping good records exerts a positive influence on the physician to maintain the expected standard. This is a win-win situation.

The guide of Mahoney and colleagues is a good start; I look forward to seeing more. Ignoring their words of wisdom is fraught with danger

[Author Affiliation]

Alan A. Bassett, MD*

[Author Affiliation]

*For a number of years Dr. Bassett acted as an expert witness for the Canadian Medical Protective Association in the field of alleged mismanagement of breast lumps. He is currently acting in this field in a freelance capacity for both defence and plaintiff Correspondence to: Dr. Alan A. Bassett, 626 One Benvenuto Place. Toronto ON M4V 2L1