Diagnosis Roulette

Every minute someone’s life takes a terrifying detour, not down a dark alley, but into the sterile, bright halls of healing. They walk in, seeking care and find themselves plunged into a nightmare. Most malpractice claims in hospitals are related to surgical errors, whereas most claims for outpatient care, which accounts for more than half of the paid malpractice claims, are related to missed or late diagnosis.

Now, before you raise a pitchfork at every white coat you see, let’s be clear. This isn’t an indictment. It’s a revelation. Because the truth is, any provider, any nurse, any human being capable of brilliance is also capable of a mistake. This is about understanding why and using that knowledge to build a safer future for every patient who walks through those doors.

Welcome to FHEA’s Scrubs and Subpoenas: Tales from the Witness Stand, a podcast where we’ll peel back the sterile sheets and delve into the real stories of medical malpractice. Each episode a cautionary tale, a blueprint for change, a reminder that even in the darkest corners of human error, there’s a light, the light of knowledge, the light of empathy, the light of a future where healthcare becomes not a gamble, but a guarantee.

So join us as we dissect the mistakes, illuminate the flaws, and ultimately learn to heal not just bodies, but the very system itself.

Jannah Amiel: Hello and welcome back to another episode of Scrubs and Subpoenas: Tales from the Witness Stand. I am your host, Jannah Amiel. And joining me is our guest, Dr. Sally Miller. Dr. Miller, how are you? 
 
 Sally Miller: I’m well, thank you. And you? 
 
 JA: Good. Thank you. Thank you. Now, for those of us, not us, because I listen to it, I’m hosting it.

Those of you that are listening and maybe for the first time, this is our podcast where we talk through some real key patient studies, patient cases, I should say, not studies, that have actually happened. Right. So, when we think about things like medical errors that we all know very well, right, if you’re a nurse or even if you’re not, if you’re working in healthcare, certainly the medical areas is one of the things that you have heard about.

You’ve had to learn about, you’ve had to take CEs about right. But these are actual real cases, real things that have happened in practice, in healthcare that we are going to talk about and break down together and kind of work through and see where we can pull some learnings from. Now, Dr. Miller is an expert witness, right?

So if you’ve listened to our first episode, we talked a little bit about what an expert witness is. Dr. Miller, can you just give us a little brief blurb on that? What does that mean for you? 
 
 SM: Well, from my place in the world and expert witnesses, I have no particular training that way. I didn’t go to a legal nurse consultant, you know, course or anything like that.

I am somebody that attorneys will seek out if they need someone to review a case and try to support their position. So I’ve been retained by defense attorneys to defend the actions, obviously, of an APRN. I have been contacted by plaintiffs attorneys to evaluate the care of an APRN. And so whenever I am contacted, typically if it’s a defendant, there’s an insurance company you know paying the bill and the insurer has to approve the expert.

So they will review this CV, make sure that it meets their criteria for an expert. Also, every state has its own requirements about the background of an expert. How recent your experience has to be, how closely aligned to the circumstance. So, there’s all sorts of little nuances there. But in the end, it mostly comes down to evaluating the care of an APRN.

And from an objective perspective, I mean, I don’t go into it saying, okay, my job is to defend this person or my job is to critique this person’s care. My job is to review the record and review all of the documentation in the notes, the depositions and anything else that’s available and form an opinion about the care provided.

Many times I can support the position of the attorney who has contacted me, but on several occasions I have not been able to support that position. And then I just tell them that when I say this, this is my impression of this case. I cannot support your position. And then I’m out of it. 
 
 JA: Yeah, that’s very interesting.

And then, of course, with that, you get to see and hear some of these unfortunate stories that you know that happen in real life when things go wrong, right? When something wasn’t done that should have been done or something was done that shouldn’t have been done. And in saying that before we happen to this next case, we want to recognize that mistakes happen.

Right? We talk about this in all our episodes. Mistakes happen. It can happen to any single one of us at any point in time. So, this is not to judge, right. This is not for us to cast judgment in this way, but to listen and to learn, to recognize that we aren’t immune to it and hopefully that we can pull things from this that help us to practice safer, help us to advocate better for ourselves as providers, learn for our patients that are coming to to us in healthcare for help.

So with that, Dr. Miller, lay it on us. What’s your case? 
 
 SM: That’s really what it’s all about, really, is learning from these, learning how we can do better work going forward and how we can better document going forward. So, this and I do like every case I look at, I really feel it viscerally like that could have been me that did do this or didn’t do that or didn’t write this down that way.

And so I know I’ve learned from them, which is why I think it’s helpful to share them with others. So, this particular case is about a 45-year-old woman and she was hospitalized with an abdominal problem, like her original problem had nothing to do with the case at hand. She had a medical history. I forget all the particulars at this point, but she did have some medical chronicity; and she has been admitted to the hospital for evaluation of left lower quadrant pain.

And I think it turned out to be ultimately inflammatory bowel disease. But she had this pain, you know, she had gone to an emergency room. There was no obvious, immediate source for it. So, anyway, she was admitted, she had a CT scan of the abdomen and pelvis. So, the hospitalization was evaluating the abdominal thing and they did figure out what it was.

Like I said, I believe it was inflammatory bowel and that was that. So, she had rectal bleeding and she had this discomfort. And in the course of working that up, she had this abdominal and pelvis CT and there was an incidental finding of a breast mass, the lower right breast. It wasn’t what the scan was looking for.

You know, the scan was concentrating on abdomen and pelvis, but it just happened to capture some of the breast tissue. And in that breast tissue was this breast lesion. This breast mass, which, side note, many times when we find malignancies early enough to intervene, they are found accidentally just like that. You know, a lot of things like ovarian cancer, for instance.

Ovarian cancer is a dangerous cancer and it doesn’t have symptoms early on. So, and there’s no screening for it. So, by the time it progresses to the point that the ovarian cancer causes symptoms, the treatment for it is much more challenging. But if you have a CAT scan for some other reason, you know, some totally other reason and find this little lesion on an ovary.

That’s when it’s much more amenable to early curative treatment. So, there is a real value in these diagnostic studies and picking up these incidental findings. So, this lady had this incidental finding of a lesion on the, you know, in the right lower breast. It wasn’t the reason she was in the hospital and there wasn’t an immediate issue with it.

So, she was just advised upon discharge to follow up with her primary care provider and that’s appropriate. You’re hospitalized for the abdomen. They find the problem with the abdomen, treat the abdomen problem. But, oh by the way, we saw this other thing. You should follow up on that. So, she was advised to follow up with her primary care provider, which she did.

She was not, I didn’t get the sense that she was communicated any real urgency. And so she got an appointment, her primary care provider, 15 days later, which is not unreasonable. I mean, you know how it goes if you call your primary care for an appointment and you know you’re not at death’s door, he’ll say, yes, we have an opening for you two weeks from now.

So, she had her appointment 15 days later and she went in and she, you know, she presented to the NP with this history. She said, I’m here because I had a CAT scan and they found this thing in my breast and they said I should come see you about it. So, the NP then proceeded to do it, you know, do a visit.

She documents that the chief complaint is, you know, follow up of this breast lesion following incidental finding on a CAT scan, and she documents a history of present illness that was really, you know, fairly limited about the absence of any breast symptoms. She does a physical exam to include head, ear, eyes, nose, throat, heart, lungs, but no documented breast examination.

And then she orders a mammogram. So, she orders a mammogram and the patient goes and has the mammogram. And the mammogram is reported to the APRN, who evaluates it nine months out. Nine months. And nine days after it was returned to her. So, there’s a timeframe here. Fifteen days out of the hospital, she sees the APRN and mammogram is ordered.

She calls to schedule it, she gets it scheduled in a month. And again, there’s no urgency communicated here. So, it’s scheduled a month out. So, it was done a month after the appointment, nine days after the mammogram was done. The APRN signs off on it and it signs off as it was read as benign.

So, we know when you see a radiology report, it’ll have the report from the radiologist typically at the top has a brief blurb on why the patient was there. You know what we refer to as clinicals? Like the reason they present. And then there is the technical report of what they saw. And then there is an impression at the bottom, right.

Each of the components. So, the clinicals on this mammogram said, ‘patient without any breast symptomatology.’ So, those were the clinicals reported to the radiologist for the interpretation of this mammogram. The radiologist was just informed that the patient was there for a mammogram, didn’t have any breast symptomatology. And so then the APRN signs off on this report.

Nine days after the exam, no further evaluation was performed on the patient. No, you know, no further workup or anything like that. The patient came back to her primary care provider about three months later for a completely unrelated complaint. You know, an URI or something like that. And the APRN in that visit documented the purpose of that visit.

But then as a side note included that the mammogram of three months prior was okay, and I’ll quote, “okay” because that’s exactly how it was written. Mammogram of whichever month was okay. And that was that. There was no further discussion of the CT finding of the lesion. No breast exam was performed, no nothing. Six months after that, the patient comes back to this same APRN complaining of a right breast mass.

That was very painful. The APRN now does a breast exam and documents a hard egg-sized abscess and diagnosed an inflammatory breast mass. The patient was referred immediately for a mammogram ultrasound and immediately diagnosed with metastatic cancer. As a result of this, she had it was inflammatory breast cancer, which is very progressive. So she had bilateral mastectomies, chemotherapy, and radiation.

The patient survived, at least, you know, at my last involvement with that case, which was a couple of years after it occurred. The patient was still living but had bilateral mastectomies and had undergone chemotherapy and radiation and all the attendant consequences and associated risks, etc. And so, I mean, it’s a brief story, but there is so much that we can pull out of this year for all of us to learn going forward.

JA: Yeah, there’s a quite a bit to unpack here now. Now, like coming back to the beginning, those GI symptoms that the patient was having, like the bleeding, right? Or she had the rectal bleeding, the left lower quadrant pain, that was completely unrelated? Right. It was just the happenstance that in diagnosing that, there’s that where they first kind of encountered the mass on imaging.

SM: Yes. So, the only, it was the complaint that was all unrelated, the breast mass. It was just happenstance that the CAT scan picked up part of the breast tissue because they weren’t doing a CT of the chest. Just on a side note, and this really is peripheral. No, but nobody would jump to this conclusion.

But like I said, I believe that the rectal bleeding and the discomfort was ultimately diagnosed as inflammatory bowel disease. An inflammatory bowel disease is an autoimmune disorder that does increase your risk for certain cancers. It increases the likelihood that it would happen. So, you know, you wouldn’t say, oh she had inflammatory bowel disease, therefore this breast mass must be cancer.

No, nobody would go there. Nobody would jump to that. But the presence of inflammatory bowel disease does increase your risk for certain cancers. And so it’s one of those things that should always be, you know, in the back of the brain here and for anyone who doesn’t know it now, you do know going forward, IBD for sure increases your risk of colon cancer.

And there is a certain genetic link in some certain circumstances between colon cancer and other reproductive cancers of women. 
 
 JA: Okay, that’s interesting. I didn’t know that. Now. No. Okay. So, then it seems appropriate, right? Didn’t doesn’t sound suspicious that you would then be referred to your primary doctor. But when you talked about the patient being at her primary, she got a mammogram, but it didn’t sound like there was, like a physical assessment of the breast and that is important, yes?

SM: It is important. And, you know, it took me some time to understand this, like as an early, as a young clinician all those many decades ago, I just, I remember thinking, well, you’re going to have a mammogram, you have a mammogram. Why do you need the breast exam? But that’s not the way to think about it.

These are different tools. Each thing can demonstrate something different to you. And there are cases where there are masses that are palpated and not visualized on a mammogram. And there are things that are visualized on a mammogram that are not palpable. Sometimes it’s really not like the mass, the actual mass that is the big clue.

But there might be a skin change, you know, like a dimpling, that classic, you know, orange peel look or a skin retraction or a nipple change or a nipple discharge. And those are all things that you find by way of physical examination. So, planning a mammogram doesn’t preclude the need for a breast exam by any stretch. And when the chief complaint is I’m following up on a breast mass, I mean, this is also something that we just teach at the very basics of physical examination.

When somebody presents with a problem area, you look at that area. I mean, you have to look at it, you have to inspect, you have to palpate, auscultate, percuss as appropriate, whether it’s chest pain, back pain, leg pain, ankle pain, like whatever is going on. You look at the area. And so, yeah, if somebody comes in because they’re there to follow up on an incidental breast mass that was identified on CT, I really can’t think of any reason not to do a breast exam and document your physical findings unless the patient refuses the breast exam, in which case you then document that the patient refused it and that you advised of the potential risks of doing so. 
 
 JA: So, that kind of sounds like the first I don’t want to say drop the ball, right, But this is kind of the first, like we missed this opportunity here for the patient. And I don’t know, right, because I’m not a clinician in this way, but if in a physical exam versus just a mammogram, is there anything that you would be able to identify if you had done a physical exam, if a practitioner was doing a physical exam of the breast, could that help to identify that this is something serious, not something that, you know, we can wait a little while to deal with?

Like, would you get actual clues from that? 
 
 SM: You could or it may have been too early. You know, we’ll never know for sure. But a really appropriate breast exam involves positioning, you know, the patient in different positions to stretch skin, pull it taut over like sometimes the breast might look normal on a just blanket inspection, but when you pull skin a certain way, it causes a change in the skin presentation that makes it apparent that there’s something there.

And then like I said, sometimes it’s not even just about the lump or the mess itself, but more superficial in appearance changes in the breast, that that gives you a clue that something’s wrong. If you see that change in skin presentation, if you see the widening of pores, that orange peel skin, you know, they in themselves are real reasons for concern.

So, there certainly, there could have been something there. You know, we’ll never know if there was or wasn’t because it’s not documented, but there certainly could have been. 
 
 JA: Now, talk to us about what you mentioned about the radiology, like the clinicals that you spoke about. That’s actually the first time I’d ever heard about that. I thought, you know, in my brain, like if you’re getting imaging, you’re getting imaging, you just say, go get imaging, take a picture of that because something’s wrong.

But like, you don’t have a lot of details. I had no idea that there was, like different pieces to that. A lot of people don’t. A lot of clinicians don’t. Even you know, new ones are learning and or somehow this does get missed sometimes in the educational process. I’m not sure how, but this is really an important point for everybody listening to this, clinicals really matter, the more information the radiologist has to work with, the more they can examine that particular part of the body for that thing.

Like by way of example, like a screening mammogram is just something every woman over a certain age should have. I’m not saying the actual number because different guidelines vary a bit. You know, some say 50, some say 45. What we can all agree for the sake of discussion that every guideline out there on breast cancer screening for women says that all women over 50 should have a mammogram.

So, you don’t have to have a lump or a bump or a complaint or a CAT scan or nothing. If you’re over 50 and you’re female, you should have a mammogram. And so this is called a screening mammogram. And it’s a two-view film. It’s a really routine assessment. It’s not detailed. Screening mammograms can be done and en masse like, you know, the mammograms sometimes will go out to reach, you know, underserved populations.

And they take the films all day long and then take them back. And then the radiologist looks at them later. You know, that’s a classic screening mammogram. It’s like if I showed you a picture of a house and I said, “Hey, you know, check out this house. Do you see anything that looks weird?” You know, you didn’t look at the house.

No, no. You know, look at the roofs. Look at the doors, look at the windows. I don’t know, the shingles, the grass, the gate, whatever. You look at the house and say, “No, it looks okay to me.” But if I showed you a picture of a house and I said, “Can you look closely at the right side of the fence?

Animals are getting through it. Somebody is getting in here every night and eating my vegetable garden or something like that. Like there’s something not right about the fence.” Now you’re really going to zoom in on that fence. You might have missed it before because nobody drew your attention to it. But now you’re going to pay attention and maybe you’ll see like a little notch or something.

It doesn’t look quite right there and then say, yeah, there’s something about that. Let’s get an ultrasound of the fence. Let’s biopsy the fence or do an MRI or something like that. That’s the difference between a screening mammogram. That’s one of the differences between a screening mammogram and a diagnostic mammogram. The clinicals are an important part of the distinction.

So, when I say clinicals, I’m really referring to any information that is relevant to the reason for the study. And the more that the radiologist has, the better their study is. I mean, it’s really not like you just look at an image and say, you know, check this out. Sometimes we’re talking about tumors that are like a couple of millimeters and nobody’s even going to see them if you don’t point them in the right direction.

In fact, side note here, just last week, I had a patient with, totally unrelated, she’s having some mental health symptoms and she asked if it could be due to menopause because she’s like 50. And I said, well, sure, menopause does trigger symptoms. Then, she told me she had a total hysterectomy 15 years ago. A total hysterectomy, you know, uterus, eggs, the tubes, ovaries, the whole thing.

And I said, well, if you had a hysterectomy 15 years ago, you’re not going through menopause. And she said, “Oh yeah, well.” And I said, “Did you take hormones?” And she said, “No.” And I said, “You had a total hysterectomy. Did anybody leave a little quarter of an ovary?” Because sometimes in young women, they will leave the smallest piece of an ovary to release hormones so that the woman can have a normal menopausal evolution.

Right. And I said, but I said to her, “It’s really important to know that.” She said, “I just had an MRI and they said there was nothing there.” And I said, “They weren’t looking at it.” I said, “When you go back for your follow up appointment, tell somebody exactly what you’re telling me. Like, tell the person who ordered this MRI that you think you’re menopausal and can they go back and look.” Because it’s really important to know from my perspective, if there is a hormonal fluctuation going on or not.

But my point here is that somebody could miss that little piece of an ovary because you’re just eyeballing something else entirely. There’s no uterus, there’s no tubes, there’s no apparent ovaries. Somebody might miss that little piece of the thing. So, takeaway story is clinicals matter. When you’re trying to get information from a radiologist that the more information you can give them about what you’re looking for, the better equipped they are to examine it really closely.

So in this case, there were no clinicals. I mean, the radiologist didn’t know that there was a mass identified on CT. The other issue here is that a screening mammogram was done, not a diagnostic mammogram. And I don’t know if that was on your list of questions. I don’t want to jump the gun. 
 
 JA: No. I mean, I think that that falls right along in line with, like, the difference between like having the clinicals and assuming that diagnostic and screening are the same.

But they’re not, they’re clearly not. So how are those different? You know, I think the misconception that I have right is just that an image is an image, and it’s up to the person who’s looking at it. 
 
 SM: Yeah. And with mammograms particularly, there’s a difference in the technique of a screening mammogram versus a diagnostic mammogram and even a difference in the reading.

Screening mammograms can be read later. Diagnostic mammograms, there is a radiologist evaluating the films as they’re being done, like there’s somebody in the vision room looking at them as they’re being recorded so that they can further direct additional views if it’s necessary. So, yeah, screening mammogram is just two views. So, it’s a real quick chop chop. Diagnostic mammograms can do all sorts, like I don’t remember how many are the starting point for a diagnostic mammogram.

But it’s way more than the two basic views of a screening mammogram. So, you’re looking at the breast from several different perspectives. And then with a radiologist right there reviewing it, the radiologist will sometimes say, all right, you know, on this one, do this other view and this other view and this other view. 
 
 JA: That’s interesting. And I didn’t know that.

SM: Yeah, they’re really very different. Screening mammogram versus diagnostic mammogram. And so, one of the things that we can go back and Q-and-A here is that you don’t do a screening mammogram when you’re doing the mammogram for any complaint or a symptom or finding. Screening is for a benign, asymptomatic patient. If you’re evaluating an existing lump, you know, like was being done here, that needs to be a diagnostic mammogram.

JA: Wow. And then and saying that, too. So, she had the wrong mammogram. This was not appropriate for this patient. And then it kind of took a while. It sounds like it just took a minute before that was even read and something like this. I mean, obviously, it doesn’t sound like the APRN recognized that this was a serious issue.

Right. That was happening with the breast. But it’s inflammatory. Breast cancer is pretty serious. And so, it sounds like this would be something that maybe should have been more urgent as far as reading that diagnostic. 
 
 SM: Yeah. You know, the inflammatory breast cancer is really rapidly progressive. So, it can get away from you very, very quickly.

The mammogram, the initial screening mammogram that was reviewed, you know, months prior, like what turned out to be six months prior to the diagnosis, taking nine days even to review that. I mean, that’s, there are so many assumptions that people make, like if there’s an issue, the radiologist will call you. Some clinicians assume that, you know, they assume that’s just something that needs immediate attention.

The radiologist will call and tell you; sometimes they will and sometimes they won’t. We can never count on that. Looking at it nine days later. I mean, nine days is a bit long, but in day-to day-world, I see how it happens. You got a stack of stuff in your inbox. You keep meaning to get to it.

And when I say inbox, it’s pretty much computerized now. You know it’s all in your task box on the computer. You know, there are other cases we will talk about with APRNs who didn’t look at the task box. So it happens. Nine days is certainly on the long side, especially for somebody who sees patients on a full-time basis.

I mean, in a perfect world, you look at your task box every day and see what’s in there and get rid of it in real life. Sometimes it takes a couple of days and then for other reasons, days get by you. In this case, nine days is a little long. But what’s really most I think, what we could learn from like what we can Q-and-A here was in looking at that report nine days later, the realization that it was a screening mammogram, not a diagnostic one, and the realization that the radiologists thought there was there was no symptomatology, that there was no reason for this other than a routine screening.

Like that’s the thing that right off the bat, you know, we’d be like, whoa, no, sorry. So sorry, Mrs. Patient, we have to do this again. 
 
 JA: Right? 
 
 SM: Because you do have a lump there and we have to look.
 
 JA: Clearly had symptoms and clearly had a lump. So, the follow up then also seemed quite long. I mean, there was months in between.

And then, Sally, I heard you say that it was like egg, egg-sized or egg shape, which sounds very big at this point. 
 
 SM: It does sound very big. And so, I’m sure the reason there was no follow up is the APRN was moving on the assumption that it was fine. No, looked at this, looked at this mammogram and said the screening mammogram, the exam was read as benign.

So, she probably thought, “Okay, 45-year-old woman, it’s benign.” The real issue here is not having the right mammogram and not supplying the clinicals because if she thought it was a benign mammogram, now there’s really no reason to order another one, at least, you know, at least for another year. And it was the patient who came back with that egg-sized thing.

And that does I mean, that could have happened really, you know, in a matter of weeks. The patient could have gone from zero to those kind of symptoms of the inflammatory breast cancer. 
 
 JA: Wow, that’s really frightening. 
 
 SM: But the real, you know, this thing I mean, on the CAT scan, the thing was 1.2 centimeters in the world of breast lumps.

That’s a pretty good sized lump. And, you know, the real issue here, it came out later, subsequently in deposition that the APRN didn’t know the difference between a screening and diagnostic mammogram, like in her deposition. She was you know, she admitted that she just didn’t know the difference between the two. So she was clearly, you know, a little bit out of her wheelhouse on that one, which is another reminder for all of us that if we’re going to evaluate a thing, we assume responsibility for knowing what we’re doing.

And if you don’t, for anyone who’s listening that maybe isn’t feeling good about this, well, then perhaps the thing to do was to refer that patient to a woman’s healthcare provider. 
 
 JA: Yeah, you know, that was going to be one of my questions: if you felt like ever, you know, as a primary care provider that this was something that maybe which is a little bit out of what you normally do and you weren’t sure, is that appropriate?

Is it appropriate to say, like, let me send you to so-and-so instead, who could help, you know, continue this on? 
 
 SM: Oh, not at all. If you being you being any diagnostician, if something is out of your, if you feel like it’s out of your area of expertise or you’re looking at a result, you don’t know what to make of it, not only is it a good idea to refer, but it’s really your responsibility.

You know, you do own this patient, you have it, you know, you accept this patient, they’re your patient. You’re evaluating this complaint. If you don’t know what to make of it or you’re not sure, which also happens to all of us, all the time. Not all the time, but it happens to all of us once in a while.

If you’re not sure, it’s time to refer it on. But what’s not appropriate is to just not, you know, not do anything with it. If you’re not sure what’s going on. And what you also don’t want to do is just assume that everybody else that’s involved in the care will let you know if there’s a problem. Because, I mean, I’ve heard that, too.

Like, well, you know, the radiologist said it was benign. And of course, in this particular case, the radiologist was also being sued. You know, there were several people named in that suit. But the radiologist position was like, look, you know, nobody told me there was a problem here. And this was referred to me as just, you know, a screening mammogram.

And on screening mammography, here are the films. This is what it looks like. I didn’t see anything here. 
 
 JA: Wow. Wow. That is really, that’s scary. And that’s unfortunate for the patient. But it sounds like, I mean, if there is a silver lining that she did survive this. And fortunately with a double mastectomy. But it is still very sad to hear that. 
 
 SM: She did.

And, you know, mastectomies for women. I mean, that’s a whole other aspect of consequence, you know unintended consequences and managing that. Not to mention the fact that with chemo and radiation those things put you at risk for other cancers further down the line. You know, the radiation increases your risk, the chemotherapy, and the attendant permanent consequences of that depending on the type of chemo she had.

Sometimes there are neuropathies. So, I don’t know, I know she was 45 when this first started. And at my last involvement she was still living, thankfully. But I don’t know how long that came out. You know, metastatic cancer. Unfortunately, there is a recurrence rate and with inflammatory breast cancer because it’s so rapidly progressive, that’s a big concern.

So, it’s very possible. That is very possible. She had a shortened life expectancy because of it. 
 
 JA: Yeah, it’s very unfortunate either way. Wow. Is there any final thoughts or, you know, takeaways that you’d like to leave us with, Dr. Miller? 
 
 SM: Yeah, for this one. You know, like we said, if you aren’t sure about what you’re doing, if you’re not sure about how you approach a clinical problem or you’re not sure what to do with the finding or something doesn’t make sense.

If you have any uncertainties at all, you have to escalate it to the next, in some way. Whether you seek consultation with someone or you send the patient off with consultation. I mean this could have been as simple as running it by a more experienced well, this NP had several years experience. I mean, this was not a new clinician.

This was someone with over ten years experience as an NP, but maybe running it by somebody with more experience in that field, like a women’s health colleague. You know, lots of us have relationships with specialists and will refer the patient when appropriate, but sometimes just pick up the phone and say, “Hey, I got a question for you.” You know, like, “Hey, what do you think?

Like this? This CAT scan showed a 1.2 centimeter lesion and the mammogram said it’s benign. Should I be worried about that? Should I take that forward?” You know, like there’s at least that if not sending the patient actually to a woman’s health provider. And the other thing is the difference between a screening mammogram and a diagnostic mammogram. Everyone who’s ordering mammograms ought to know the difference between the two and the implications of them when they’re indicated.

And then the importance of clinicals. Yeah, clinicals are a pain. I mean, they are a pain. You’re like in a hurry. You’re five patients behind the computer program is not working right. It wants you to click a thing you didn’t click like. That’s the way the clinical day goes. You know, from the time you hit the ground with your first patient, you’re trying to play catch up, it seems like, and just be time efficient.

And then you have to enter this order. And if something doesn’t go right, you click the wrong thing and then you have to get out of it. And the last thing anybody wants to do or type in these long, drawn out clinicals, but you have to include at least enough to give the radiologist some perspective on what he or she is looking for.

JA: Yeah, and this story is absolutely a testament to that. And certainly I’ve learned something new. But again, it comes back to advocating for your patients, right. And doing what’s best for them. Right. And then practicing safely for yourself. Dr. Miller, thank you so much for your time and thank you for sharing this case. We hope that you found this story interesting and hopefully pulled some learnings from this that you can apply to your day to day as we keep on moving forward with our best practices out there in the world with our patients.

Thanks for tuning in. If you like this episode, check out more at FHEA.com. Goodbye for now. 

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