Tuesday, July 17, 2012

Psychiatrist's Failure to Diagnose Results in Defense Verdict Prior to New Standard

As I discussed in my last post on psychiatric malpractice, recent studies have determined that psychiatric patients in Pennsylvania with brain tumors may present with a variety of psychiatric symptoms for a sufficient period of time without obvious neurologic symptoms and signs.  As a result it has become the standard of care for psychiatrists  to consider brain imaging not only for psychiatric patients with neurologic symptoms and signs, but for all psychiatric patients who present with atypical psychiatric symptoms, with late onset of psychiatric symptoms (>50 years of age), or when there is a change in clinical presentation of psychiatric symptoms.  My research suggests that this recommendation has become the standard of care more recently.  This may explain the outcome in the matter of Foster v. Hicks, M.D. a case where the plaintiff's theory was that his psychiatrist failed to diagnose his brain tumor.

In 2001, plaintiff Craig Foster, 18, a high school student, began experiencing cognitive and neurological problem, including memory impairment, odd use of language, headaches, sweating, tremors and numbness in his left hand. On Dec. 3, Foster saw psychiatrist Sarah Hicks in Philadelphia. Hicks diagnosed Foster with hypochondriacal panic attacks and prescribed Zyprexa. Foster continued treating with Hicks through 2002, at which point he was still suffering from headaches.

On Jan. 7, 2003, Foster's primary care physician ordered an MRI of his brain, which showed the presence of a large tumors measuring 3.4 x 3.4 x 2.9 cm. On Jan. 10, Foster underwent surgical decompression of the mass, which was later diagnosed as a craniopharyngioma.

Claiming medical malpractice, Foster sued Hicks, alleging that she failed to diagnose his brain tumor. Plaintiff's counsel argued that Hicks failed to obtain all of Foster's medical history and records from his parents and health care providers. Plaintiff's counsel further argued that Hicks failed to advise the necessary diagnostic testing to rule out a brain disorder, and failed to recommend and/or perform cognitive capacity screening tests. Plaintiff's counsel further argued that Hicks failed to recommend and/or perform such other tests as were necessary and indicated, especially in light of Foster's clinical presentation and history.

Plaintiff's psychiatry expert testified that Hick's substandard evaluation and follow-up treatment of Foster resulted in a significant delay in his diagnosis and thus directly contributed to the nature and severity of his clinical condition and his limited response to surgical intervention, his ongoing significant oncological and neurological conditions, and his endocrinological impairment.

The defendant denied the allegations. The defense psychiatry expert, testified that the care that Hicks provided to Foster was reasonable and appropriate. Emanuel Rubin, defense endocrinology expert, testified that since craniopharyngioma grows very slowly, the tumor very likely had been present for many years, and it was improbable that any significant growth occurred in the one-year interval between referral to Hicks and surgery for craniopharyngioma. Rubin further testified that any delay in diagnosing Foster's craniopharyngioma that occurred during his psychiatric treatment by Hicks played no role in the development of endocrinological problems. Stephen Fedder, defense brain and spinal surgery expert, testified that significant interval growth of a tumor from March 2001 through January 2003 was unlikely.

Following the Jan. 10 operation, Foster had an MRI that showed residual tumor, measuring 2.2 x 1.4 x 1.6 cm. He underwent radiation therapy from Feb. 19 to March 31. He then developed panhypopituitarism and diabetes insipidus, which was treated with hormonal replacement, and as a result missed a semester of college due to the treatment. Serge Jabbour, plaintiff's endocrinology expert, testified that if the diagnosis of Foster's brain tumor had been made earlier, there was a higher chance that his endocrine function would have been preserved preoperatively or would have been recovered, either partially or totally, if the surgery were performed sooner. Jabbour also testified that the combination of Foster's surgery and radiation treatment could lead to hypopituitarism; that Foster's prognosis was good; and that recent brain MRIs have been stable.

Foster sought an unspecified amount in damages for past and future pain and suffering.

Fedder testified that there was no cognitive deficits related to any alleged delay in diagnosis as demonstrated by Foster's B+ GPA in college and Foster's current job as an accountant, and that there were no visual changes noted since Sept. 28, 2004. Rubin testified that Foster did not suffer any cognitive or neuro-opthalmic problems, and there was no reason to believe that any such symptoms would develop in the future.

After a lengthy deliberation the jury found the defendant doctor not guilty.  I can only wonder if the current standard of care, applied to this case, would have resulted in a different outcome.

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