The Expert: Dr. Frank Pomposelli, a vascular surgeon and Chair of the Department of Surgery at Massachusetts’ St. Elizabeth’s Medical Center, discusses the importance of a differential diagnosis when treating patients, and the fact that the treating physician in this case should have considered the possibility of a vascular condition earlier in his treatment.
Testifying in a 2015 Florida medical malpractice and false advertising trial, Dr. Frank Pomposelli, a vascular surgeon and chairman of the Department of Surgery at St. Elizabeth’s Medical Center in Boston, addresses the defendant’s failure to diagnose a woman’s vascular problems until it was too late to save her left leg.
The focus in this video clip is Dr. Pomposelli’s explanation of, and emphasis on, the “differential diagnosis.” As he explains, the patient’s complaints and physical findings lead a physician to believe that a particular diagnosis is most likely, but other possibilities are always conceivable. This list of possibilities, with the most likely diagnosis at the top, is something that is basic to medicine and occurs in all medical specialties. It is important to go through this step because of the variability in each patient’s presentation and physical findings. If the doctor’s original diagnosis is incorrect, another diagnosis should be immediately considered. This is especially evident when the treatment for a particular diagnosis is not working.
In this case, however, the expert saw no evidence that a differential diagnosis was used. The expert explains that, “… [T]hey locked onto a diagnosis of leg pain related to degenerative spine disease… they never considered the possibility that something else might be going on.”
In this case, the patient’s symptoms could have been consistent with degeneration of the spine or with vascular disease. Either diagnosis fits the presentation of leg pain with walking or at rest. “You always have to consider both,” says the vascular specialist, who receives requests for consultation to determine whether cases like this are due to vascular pathology “all the time” from many different types of physicians. Here, however, no vascular specialist was asked to evaluate this patient until things were too far gone.
Pomposelli reviews the timeline of events during his testimony and comments that it is a little unusual for patients with a diagnosis of spine degeneration not to complain of back pain, as was the case with this patient.
The defendant doctor recorded no evidence that he ever considered vascular occlusion as the cause of the patient’s leg pain, and instead referred her to a neurosurgeon for treatment of the spine degeneration. The neurosurgeon then obtained an MRI, which demonstrated some moderate spinal pathology. The neurosurgeon twice ordered epidural cortisone injections for treatment, neither of which had the desired effect of alleviating her pain. In fact, the pain seemed to worsen, making it more difficult for her to walk shorter distances, with radiation down her lower leg into the foot. “This is the point that I would get concerned that things were not what they appeared to be,” the expert testifies.
The treatment has not led to improvement, and in fact the symptoms had worsened. The signs and symptoms were consistent with vascular disease as well as spinal degeneration, but since the treatments for the latter were not effective, the former needed to be considered. Failure to consider vascular pathology in a timely manner could lead to devastating disasters when the extremity is deprived of its blood supply, as occurred in this case.
The doctor’s testimony for the plaintiff helped result in an $8.54 million verdict.
Gary Gansar, MD, is residency-trained in general surgery. He served as Chief of Surgery and Staff at Elmwood Medical Center and on the Medical Executive Committee at Touro Infirmary and Mercy Hospital in New Orleans, LA. Dr. Gansar was Board Certified in general surgery while in active practice. He joined AMFS in 2015 as a Physician Medical Director.
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