Case 12 A runner with a cough

Fiona consulted Dr Enderby with a three-month history of cough. The cough occurred predominantly on exertion but also sometimes at night and it was not productive. She had not noted shortness of breath particularly, but was training for a marathon and felt her running times were less good than they had been. On direct questioning Dr Enderby established that Fiona had lost a little weight but she was running 60 miles per week in her training. She had also had an eating disorder in the past. Dr Enderby noted that she had a past history of asthma. She was a nonsmoker. Examination was unremarkable, other than that Dr Enderby thought that she looked a little gaunt and underweight. Her PEFR was 500 l/min.

What would you do now?

Dr Enderby treated her for asthma and saw Fiona four times in the next 8 weeks. Initially her symptoms seemed to improve but then she re-presented three months after her initial consultation. Fiona had run her marathon in a reasonable time but felt that, after the initial ‘high’ following the race her mood had slipped and she had become rather depressed. She was not enjoying her work and was beginning to worry that she would put on weight as she was not running so much. She was not sleeping because she was coughing at night. Dr Enderby started Fiona on fluoxetene and re-started inhaled corticosteroids, which Fiona had stopped. Over the next month her cough improved but her mood deteriorated and she appeared to have lost weight.

What would be your differential diagnosis and how would you discriminate between them?

Dr Enderby was concerned that Fiona was not eating but she stated it was because she was getting heart burn. Dr Enderby referred her to a counsellor specializing in eating disorders and started her on a PPI. The counsellor found that Fiona’s BMI was only 16 and requested a referral to the eating disorders unit, which Dr Enderby did. Fiona was seen three weeks later by a doctor in the eating disorders unit who was concerned that Fiona had a chronic cough and weight loss and requested a chest X-ray. This showed mediastinal lymphadenopathy and Fiona was later diagnosed with stage IIIB Hodgkins disease.

The allegations in the Letter of Claim were that Fiona had had chronic cough for seven months, weight loss for some months and night sweats for two months before diagnosis. It was alleged that Dr Enderby was negligent in that he failed to investigate the cause of the chronic cough, failed to elicit the history of night sweats and failed to monitor Fiona’s weight.

Do you think her claim will succeed?

Expert opinion

General practitioners are frequently faced with a patient with many symptoms and many possible causes. In addition mental illness, such as depression or an eating disorder, is a common finding. It is often easy with the benefit of hindsight to see that many of the symptoms were due to a final unifying diagnosis (which is often a relatively rare condition). A chest physician may well be critical of the general practitioner for failing to request a chest X-ray in someone with chronic cough. However, Fiona was a nonsmoker with a history of asthma and many general practitioners would have reasonably considered that the likely differential diagnoses were the ‘triad’ of asthma, gastro-oesophageal reflux or post-nasal drip syndrome and carried out ‘trials of treatment’ before requesting a chest X-ray. A general practitioner will not routinely investigate a patient in the way that a specialist will.

However, a further difficulty about being a generalist is that it is usually necessary to try and integrate disparate bits of information about a patient’s history. In this case the allegation was that Dr Enderby was aware of the history of chronic cough and weight loss but, while ascribing them to asthma and an eating disorder, failed to consider the possibility that they may be related. Dr Enderby was criticized for failing to follow up on the history of chronic cough (though it was persisting), failing to consider a differential diagnosis for the weight loss and failing to monitor the weight loss (document the weights) and investigate the same before assuming that it was due to an eating disorder.

This is a type of case that tests the standard required of general practitioners. It is possible that different experts would have different opinions in a case like this. Dr Enderby’s actions were not ‘careless’ in the accepted sense of the word (one of the definitions of breach of duty). At each stage he had a plausible diagnosis and acted appropriately for that diagnosis.

However, the standard required diagnostically is likely to be quite high for a well-paid and highly trained professional. In this case Fiona had a long history of illness and Dr Enderby’s actions suggest that he did not fully consider the differential diagnoses that were necessary to be considered. He appears to have prematurely anchored on two diagnoses and failed to reconsider these when treatment failed and the initial presentation evolved. My own opinion is that Dr Enderby was in breach of duty once a reasonable therapeutic trial for chronic cough had failed and once it became apparent that the (undocumented) weight loss was a significant factor to be carefully considered.

Legal comment

Expert opinion suggests that Dr Enderby’s actions or omissions are at the very edge of what may be considered acceptable practice. The expert says his own opinion is that Dr Enderby was in breach of duty at a certain point in this scenario. While an expert may have his own opinion, what is important is whether there is a responsible body of medical opinion (even if it is not the expert’s) that would support Dr Enderby’s actions. Maybe there is. If so, how sound are the reasons for this opinion?

Some difficult judgements will have to be made by Dr Enderby and his legal team. Should the case be defended to trial or should they settle? Generally, the MDOs take cases to trial that receive strong supportive opinions. After all, if the case is lost, not only will Dr Enderby’s reputation suffer but also a judicial precedent may be set which makes life harder for other doctors. Furthermore, defending this case to trial could cost the MDO several tens of thousands of pounds.

The MDO will also take into account the likely value of the claim. This will depend on the causation and condition and prognosis evidence that they receive. If the claim is of modest value, then the reluctance to take the risk will probably be all the greater.

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