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What Doctors Owe
It was an ordinary Monday at the Middlesex County Superior Court in Cambridge,
Massachusetts. Fifty-two criminal cases and a hundred and forty-seven civil
cases were in session. In courtroom 6A, Daniel Kachoul was on trial on three
counts of rape and three counts of assault. In courtroom 10B, David Santiago
was on trial for cocaine trafficking and illegal possession of a deadly weapon.
In courtroom 7B, a scheduling conference was being held for Minihan v.
Wallinger, a civil claim of motor vehicle negligence. And next door, in
courtroom 7A, Dr. Kenneth Reed faced charges of medical malpractice.
Reed was a Harvard-trained dermatologist with twenty-one years of experience,
and he had never been sued for malpractice before. That day, he was being
questioned about two office visits and a phone call that had taken place almost
a decade earlier. Barbara Stanley, a fifty-eight-year-old woman, had been
referred to him by her internist in the summer of 1996 about a dark warty
nodule a quarter-inch wide on her left thigh. In the office, under local
anesthesia, Reed shaved off the top for a biopsy. The pathologist's report came
back a few days later, with a near-certain diagnosis of skin cancer--a
malignant melanoma. At a follow-up appointment, Reed told Stanley that the
growth would have to be completely removed. This would require taking a two-
centimeter margin--almost an inch--of healthy skin beyond the lesion. He was
worried about metastasis, and recommended that the procedure be done immedi-
ately, but she balked. The excision that he outlined on her leg would have been
three inches across, and she couldn't believe that a procedure so disfiguring
was necessary. She said that she had a friend who had been given a diagnosis
of cancer erroneously and undergone unnecessary surgery. Reed pressed, though,
and by the end of their discussion she allowed him to remove the visible tumor
that remained on her thigh, only a half-inch excision, for a second biospy. He,
in turn, agreed to have another pathologist look at all the tissue and provide
a second opinion.
To Reed's surprise, the new tissue specimen was found to contain no sign of
cancer. And when the second pathologist, Dr. Wallace Clark, an eminent autho-
rity on melanoma, examined the first specimen he concluded that the initial
cancer diagnosis was wrong. "I doubt if this is melanoma, but I cannot comple-
tely rule it out," his report said. Reed and Stanley spoke by phone in mid-
September 1996 to go over the new findings.
None of this was in dispute; what was in dispute was what happened during the
phone call. According to Stanley, Reed told her that she did not have a mela-
noma after all--the second opinion on the original biopsy "was negative"--and
that no further surgery was required. Reed recalled the conversation diffe-
rently. "I indicated to Barbara Stanley that Dr. Wallace Clark felt that this
was a benign lesion called a Spitz nevus and that he could not be a 100 percent
sure it was not a melanoma," he testified. "I also explained to her that in
Dr. Clark's opinion this lesion had been adequately treated, that follow-up
would be necessary, and that Dr. Clark did not feel that further surgery was
critical. I also explained to Barbara Stanley that this was in conflict with
the previous pathology report and that the most cautious way to approach this
would be to allow me to [remove additional skin] for a two-centimeter margin."
She became furious at him for the seeming error in his initial diagnosis,
though, and told him that she didn't want more surgery." At that point, I
reemphasized to Barbara Stanley that at least she should come in for regular
follow-up." She didn't want to return to see him. Indeed, she wrote him an
angry letter afterward accusing him of mistreatment and refusing to pay his
bill.
Two years later, the growth reappeared. Stanley went to another, and this time
the pathology report came back with a clear diagnosis: a deeply invasive malig-
nant melanoma. A complete excision, she was told, should probably have been
done the first time around. When she finally did undergo the more radical pro-
cedure, the cancer had spread to lymph nodes in her groin. She was started on
a yearlong course of chemotherapy. Five months into it, she suffered a seizure.
The cancer had spread to her brain and her left lung. She had a course of
radiation. A few weeks after that, Barbara Stanley died.
But not before she had called a lawyer from her hospital bed. She found a
full-page ad in the Yellow Pages for an attorney named Barry Lang, a specialist
in medical malpractice cases, and he visited her at her bedside that very day.
She told him that she wanted to sue Kenneth Reed. Lang took the case. Six
years later, on behalf of Barbara Stanley's children, he stood up in a
Cambridge courtroom and called Reed as his first witness.
--
http://tinyurl.com/6zfx7o
http://en.wikipedia.org/wiki/Atul_Gawande
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