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Please! A Little Disclosure

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A veteran has cancer of the kidney but his care providers are unaware until the cancer grows larger and larger and spreads to other organs. What should the Director of the facility tell the patient?

This month we’re going to review the Office of Inspector General (OIG)report on Delay in Care and Care Coordination Concerns at the Cheyenne VA Medical Center and the Iowa City VA Health Care System Wyoming.

An anonymous person, most likely an employee, called the OIG with concerns about delays in care for a patient with kidney cancer. The patient had a CT scan in 2011 and was found to have a golf ball-sized mass on his kidney. He was referred to urology but it wasn’t until about a year later that he underwent surgery for the mass and was found to have kidney cancer. Apparently, the patient refused further work-up, but we’re not told if his providers truly had an informed decision with him about the risks of ignoring a cancerous finding. However, even the Chief of Staff admitted that once the patient decided on surgery, the wait for the Urology team to respond was too long.

In any case, the veteran underwent a definitive surgical procedure in fall 2012 in which his kidney and the accompanying cancer was removed. Here’s where the follow-up stopped. It’s very important to periodically scan these patients for recurrence or spread of their cancer. If these findings are detected earlier rather than later, treatment is much more effective and may lead to cure.

Multiple providers ignored the cancer findings. The patient was seen in urology but never given a future appointment; primary care saw him six times without mentioning any cancer surveillance as did home care — the latter made 73 visits to the patient’s home. And he was admitted three times without anyone realizing he needed follow-up scans.

In 2016, a surveillance MRI showed the cancer had spread and was no longer operable. The patient started on chemotherapy and radiation therapy but died a year later.

The VA has a system of notifying patients when harm has occurred. This is authorized by the Director of the facility and known as institutional disclosure. The Director is responsible to have someone contact the patient, give them their rights and responsibilities — including the right to file a lawsuit — and tell them that a medical error occurred.

Institutional disclosures are typically done for major instances of harm such as the surgeon leaving an instrument in the patient after an operation, the general medicine doctor giving a wrong dose of a potent medication, or in this case, not performing cancer surveillance.

Local VAs report the number of institutional disclosures to their supervisors at the Veterans Health Administration (VHA). Unfortunately, at some VAs this has become a paper exercise of box checking in the guise of appearing forthright. All sorts of trivial incidents are reported to keep the numbers up, while big things go unmentioned.

Sadly, it took until 2018 for their medical center leadership to decide that an institutional disclosure should be made to this patient. Would the Director have disclosed their tragic error had not the OIG investigated? We’d like to think so.

Prof. Sam

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