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SPOTLIGHT CASE
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A Loss of Trust and a Missed Diagnosis

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John Landefeld, MD, MS, Sara Teasdale, MD, and Sharad Jain, MD | February 23, 2022
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Disclosure of Relevant Financial Relationships: As a provider accredited by the Accreditation Council for Continuing Medical Education (ACCME), the University of California, Davis, Health must ensure balance, independence and objectivity in all its CME activities to promote improvements in health care and not proprietary interests of a commercial interest.  Authors, reviewers and others in a position to control the content of this activity are required to disclose relevant financial relationships with commercial interests related to the subject matter of this educational activity.  The Accreditation Council for Continuing Medical Education (ACCME) defines a commercial interest as “any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on patients” and relevant financial relationships as “financial relationships in any amount occurring within the past 24 months that create a conflict of interest.   

Patrick Romano, MD; MPH, Debra Bakerjian, PhD, APRN, RN; John Landefeld, MD; Sara Teasdale, MD; Sharad Jain, MD; and Patricia Poole, PharmD for this Spotlight Case and Commentary have disclosed no relevant financial relationships with commercial interests related to this CME activity.

Learning Objectives

  • Evaluate the ‘red flag’ symptoms associated with low back pain and implement follow-up evaluation appropriately.
  • Describe evidence-based first line treatments for low back pain and assess the appropriate role of opioid analgesics in low back pain management
  • Discuss how pain-related stigma can compromise effective, timely care for patients with chronic illness

The Case

A 65-year-old woman with a past medical history of hypothyroidism, depression, and 50 pack-years of cigarette smoking presented to her primary care physician (PCP), concerned about low back pain. She had sustained a minor fall a few weeks prior, although initially she did not have pain. At the time of her appointment, she described the pain as deep, and 6 out of 10 in severity, concentrated in her left low back. She was advised to apply ice and take ibuprofen. She returned to her PCP a few months later and reported persistent pain. A lumbar spine radiograph was performed that showed mild degenerative disc disease. The patient was prescribed hydrocodone/acetaminophen in addition to ibuprofen; she found these medications helpful. The PCP encouraged her to exercise more and try to lose some weight (her body mass index was 28 kg/m2).

At subsequent follow-up visits, her physician extended the hydrocodone/acetaminophen for an additional month and continued to encourage exercise and weight loss. In 2020, as the COVID-19 pandemic restricted in-person visits, she was seen by video twice for progressive pain—now 9 out of 10 in severity and limiting her ability to walk due to leg spasms. She requested an extension of her hydrocodone/acetaminophen prescription, which the PCP denied out of concern that she was ‘drug seeking.’ He encouraged exercise and attributed her pain to depression. Over the next several weeks, her pain continued to worsen. She began experiencing balance problems and leg spasms such that she required use of a walker to ambulate. Her family encouraged her to see her PCP; however, she refused to see him because she felt he didn’t believe her symptoms. The patient now struggled so much with activities of daily living that she required her daughter and daughter-in-law to care for her.

Finally, a year after her initial evaluation for back pain, the patient’s family brought her to the emergency room because she was unable to ambulate even to the bathroom due to pain. The emergency physician ordered spine, left hip, and chest x-rays. The chest x-ray showed a 5 cm lesion in her lung, the spine x-ray showed a small vertebral lesion, and the hip x-ray showed multiple lesions in her pelvic bones. A biopsy of the lung lesion led to a diagnosis of lung cancer, and magnetic resonance imaging (MRI) showed signs of metastases to the liver and bone, as well as multiple small fractures of the pelvic girdle. Given the extent of metastatic disease, the patient decided against aggressive treatment with curative intent and enrolled in hospice. She received morphine for pain while her family provided around-the-clock care. She died of metastatic lung cancer 6 weeks after her enrollment in hospice.

The Commentary

By John Landefeld, MD, MS, Sara Teasdale, MD, Sharad Jain, MD

Background

This tragic story highlights many patients’ and many clinicians’ worst fears of broken trust and missed diagnoses. The three themes of this case – low back pain, lung cancer screening and diagnosis, and opioid analgesics – arise daily in primary care practice and each is associated with missed opportunities for intervention that could have improved the quality of care and outcomes for this patient.

Low back pain is a common concern in primary care practice, accounting for at least 0.5% of all visits to primary care practices in 2018.1 Such pain can develop from conditions that range from being relatively benign (e.g., myofascial pain, degenerative disc disease) to debilitating and life-threatening (e.g., epidural abscesses, bony metastases). As a result, clinicians must employ evidence-based diagnosis and treatment approaches to ensure that the care they provide is safe, effective, and consistent for all patients. Approaches to the evaluation and treatment of back pain have been consistently summarized in the family medicine and internal medicine literature.2-5 The majority of patients do not require imaging. However, if low back pain does not improve with conservative therapy, further diagnostic efforts must ensue promptly. The omission of such efforts represents a diagnostic error.

In addition, there are several diagnoses that require urgent evaluation and imaging; these include cauda equina syndrome, spinal infections (spinal abscess, epidural abscess, osteomyelitis), and cancer in the spine. Clinicians should look for “red flag” symptoms and signs that may warrant advanced imaging with MRI. These include new urinary retention, fecal incontinence, saddle anesthesia, history of intravenous drug use, a past or current diagnosis of cancer, unexplained weight loss or other symptoms of cancer, and severe progressive motor deficits.5 The strongest predictor of a malignant cause of back pain is a personal history of cancer that is known to metastasize to bone.6 In this case, during her second clinic visit, it was reasonable to obtain a plain radiograph of the region of the patient’s low back where she was experiencing acute pain, primarily due to her risk factors for vertebral compression fractures from osteoporosis, i.e., her sex, age, and history of cigarette smoking. However, the remainder of the physician’s evaluation provided minimal diagnostic value. As her symptoms progressed to involve radicular symptoms with leg spasms, magnetic resonance imaging would have been indicated due to her older age (a risk factor for fracture) and long history of smoking (a risk factor for cancer).

Lung cancer is the leading cause of cancer deaths and must be considered in patients with historical or current tobacco use.7 The United States Preventive Services Task Force (USPSTF) recommends that patients between the ages of 50 and 80 years who have at least a 20 pack-year smoking history, and who currently smoke or who have stopped smoking in the previous 15 years, undergo annual lung cancer screening using low dose computed tomography (CT) of the chest.8 Other recent evidence-based guidelines suggest a smoking threshold of 30 pack-years.9 This patient met these criteria for lung cancer screening, yet she had never been screened. Arguably, because this patient’s back pain was eventually attributed to metastatic disease, this was a case of missing the diagnosis of lung cancer at both the asymptomatic (screening) stage and the symptomatic (diagnostic) stage. Clinicians must consider life-threatening causes of low back pain, such as cancer, in evaluating patients at increased risk, but the patient in this case should also have received annual CT scans of the chest for lung cancer screening.

The use of opioids for pain management in ambulatory care has come under intense scrutiny due to the concern that overprescribing opioids has contributed to the current epidemic of opioid overdose deaths in the United States. Regulatory bodies, health systems, and professional societies have all encouraged providers to taper the opioid prescriptions of people on long-term opioids and to limit new cases in which opioids are prescribed (both for acute and chronic indications). As a result, opioid prescribing has decreased in the United States; as of 2019, opioid prescribing was at its lowest level since 2006.10 In 2016, the United States Centers for Disease Control and Prevention (CDC) released “CDC Guideline for Prescribing Opioids for Chronic Pain,” which was intended to guide front-line providers on how to use these medications safely. The CDC’s guidelines included many laudable recommendations; however, some may have been interpreted less as ‘guidelines’ and more as ‘standards.’11,12 For instance, while the CDC advised that opioids for acute pain will rarely benefit patients beyond 7 days’ duration, this is not an instruction for providers to use 7 days as a firm limit. Rather, the CDC advised that treatment duration decisions must be individualized and patient-centered.

In this case, additional opioid prescriptions would not have expedited this patient’s diagnosis of lung cancer but discontinuing her therapy without an alternative approach to providing her relief led to extended, undertreated pain. Moreover, by attributing this patient’s pain to ‘drug-seeking’ and possible depression, the provider in this case prematurely closed his diagnostic reasoning in terms of identifying alternative explanations for the pain. Pain management includes analgesia but must also include a thorough diagnostic workup to ensure underlying causes are identified and addressed.

Systematic Approach to Improving Patient Safety

Diagnosis

This case demonstrates how a delay in diagnosis can lead to significant and catastrophic outcomes for patients. Diagnostic errors, defined as inaccurate or delayed diagnoses, are common in medicine; the Institute of Medicine (now the National Academy of Medicine) reported in 2015 that 5% of adults who seek care in outpatient settings experience a diagnostic error each year.13

Graber et al.14 divided diagnostic errors into three categories:

  • No-fault errors, which result from factors outside the control of the physician or the healthcare system
  • System-related errors, which include technological or organizational barriers
  • Cognitive errors, which include inadequate knowledge, poor critical thinking skills, a lack of competency, problems in data gathering, and failing to synthesize information

In this case, the physician’s initial workup appears appropriate since no ‘red flag’ symptoms or signs were evident from the information presented by the patient. However, the physician should have considered a new diagnosis and additional evaluation as the patient’s pain worsened and she developed new symptoms, including leg spasms and difficulty ambulating. At that point, given her progressive symptoms, advanced imaging (e.g., MRI) would have been helpful for establishing a definitive diagnosis. The situation was complicated by the COVID-19 pandemic when many clinic visits were converted to virtual visits and evaluation of the patient often did not include a physical examination.

Because of the cognitive error made in this case, the PCP involved would benefit from feedback and further education about the diagnosis and management of low back pain, particularly instruction regarding the need for further evaluation if the patient does not respond to conservative therapy. The physician in this case appeared to demonstrate premature diagnostic closure, as he labelled the patient as ‘drug-seeking’ and attributed her pain to depression. He did not consider alternate diagnoses despite her progressive symptoms. Ultimately, the patient lost trust in the physician because her disabling symptoms were not being adequately addressed.

Finally, all healthcare delivery systems should have systems in place to ensure that all patients receive appropriate preventive services. In fact, these services should be automated through health information technology so that busy providers who need to focus on more urgent issues are not solely responsible for arranging these interventions. Ample data suggests that lung cancer screening rates remain low throughout the United States.15 In this case, the patient should have been referred for annual lung cancer screening as recommended by the USPSTF.8 If that screening had been performed, her lung cancer would likely have been diagnosed at an earlier stage, perhaps before it had metastasized.

Management

When the patient first presented to her physician with low back pain, she had sustained a minor fall and was reporting sub-acute back pain. In an evaluation of back pain, there are three categories to consider: nonspecific low back pain, back pain potentially associated with radiculopathy or spinal stenosis, or back pain potentially associated with another specific spinal cause.16-19

At that initial visit, the physician diagnosed her with nonspecific low back pain. While this is the most common cause of pain following a fall, her history of smoking and age of 65 years should have prompted consideration of the possibility of underlying systemic disease, even if no additional testing was necessary at that time. Based on the most recent back pain guidelines, treatment for nonspecific low back pain at the initial visit with non-steroidal anti-inflammatories and conservative home measures (including exercise, topical cold or heat, and continued usual activity) was appropriate. A recent systematic review found that clinicians should anticipate about 50% mean improvement in the severity of acute back pain over 6 weeks, with complete resolution in over 50% of patients by 12 weeks after onset.20

A few months later, when the patient’s pain had persisted, the physician appropriately ordered an x-ray. However, when the x-ray showed degenerative disc disease, the physician then prescribed hydromorphone/acetaminophen (in addition to ibuprofen). Opiates should not be considered first line treatment for degenerative disc disease because this is a chronic, slowly progressive condition for which the risk of opioid therapy may exceed the modest therapeutic benefits.18 This visit was a missed opportunity. The physician should have considered whether the patient’s clinical symptoms fit with the radiographic findings and, if not, ordered further imaging. In addition, other nonpharmacological treatment modalities – such as a formal exercise program, multidisciplinary rehabilitation, massage, spinal manipulation, yoga, or acupuncture - should have been discussed as potential adjuncts to anti-inflammatory medications.17

Although the prescribed regimen of hydrocodone/acetaminophen and ibuprofen relieved the patient’s pain temporarily, the fact that the medication stopped controlling her symptoms over time should have prompted additional evaluation of the patient. A reduction in efficacy of a previously beneficial treatment could be indicative of progression of an underlying disease or development of physiologic tolerance to the medication. Unfortunately, as the patient’s pain and symptoms intensified, the diagnosis was not re-evaluated (a diagnostic error of omission). Instead, the provider discounted the patient’s report of her pain, labeling her as ‘drug-seeking’ and depressed. The labeling of a patient as ‘drug-seeking’ can shatter trust and rupture therapeutic relationships. In this case, this rupture likely further exacerbated the delay in diagnosis. Such labels, and the antagonistic relationships they can foster, may contribute to delays in screening and diagnosis because so much focus in the clinical encounter is on the contention over opioid medications.

Maintaining trust at the center of the physician/patient relationship is imperative when caring for anyone, but especially so in treating chronic pain. Conversations about chronic pain management and opioid analgesics can be difficult but conveying genuine empathy without judgment is foundational to collaborating with patients to develop a safe and effective diagnosis and management plan.21

Several added factors that could have led to diagnostic error in this case include:

  • Short primary care visits, often with multiple topics to discuss in 15 minutes or less;
  • Anchoring bias when providers are asked for opioid refills, especially by patients with a known history of depression, anxiety, or substance use disorders;
  • The PCP documented the patient’s symptom simply as ‘pain’ with little apparent effort to understand how the pain was evolving (i.e., location, type, severity, chronicity) and affecting the patient’s function and quality of life;
  • The PCP did not perform or document a physical examination to identify objective signs of motor weakness, muscle spasm, or sensory abnormalities; and
  • Appointments moved to virtual visits, which made assessments more difficult.

So how do primary care physicians, who are tasked with managing multiple chronic diseases and health care maintenance, maintain up-to-date knowledge about, and develop the skills necessary for, diagnosing and managing pain? Reviewing society recommendations or specialty publications can be a great way to start. For example, the Annals of Internal Medicine recently published updated guidelines on the management of low back pain.16-19 Providers who do not feel comfortable diagnosing and managing pain can also supplement their learning through continuing medical education courses, blogs, and podcasts to enhance their skills.

Although pain management specialists are not available in all health systems and communities, this PCP might have benefited from consultation with another provider(s) with greater expertise in evaluating and treating chronic pain. Even within a primary care practice, it may be helpful to involve a colleague to look at a case with fresh eyes when the patient’s clinical course is not improving as expected.

Take-Home Points

  • Patients between the ages of 50 and 80 years, who have at least a 20 pack-year smoking history and currently smoke or who have stopped smoking in the previous 15 years, should be offered annual low-dose CT scans of the chest to screen for lung cancer.
  • Acute back pain should generally not be managed with opioid analgesics; instead, failure of symptom improvement with conservative management should prompt further diagnostic evaluation.
  • Lung cancer may metastasize to bone, including the vertebrae, and its progression may cause nonspecific symptoms including back pain.
  • Stigma associated with opioid analgesics can contribute to diagnostic errors. ‘Pain medication seeking’ or ‘drug seeking’ are labels that lack universal meaning and may distract care providers from conducting thorough diagnostic workups.
  • Contentious interactions between providers and their patients with regard to pain medications can preempt more robust evaluations of symptoms. Tactics to prevent pain management from becoming adversarial include early and frequent communication about multimodal pain management and empathic listening.

 

John Landefeld, MD, MS
Assistant Clinical Professor
Department of Internal Medicine
Division of General Internal Medicine
UC Davis Health

Sara Teasdale, MD
Assistant Clinical Professor
Department of Internal Medicine
Division of General Internal Medicine
UC Davis Health

Sharad Jain, MD
Professor
Department of Internal Medicine
Division of General Internal Medicine
UC Davis Health

References

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  3. Last AR, Hulbert K. Chronic low back pain: evaluation and management. Am Fam Physician. 2009;79(12):1067-1074. Free full text
  4. Maher C, Underwood M, Buchbinder R. Non-specific low back pain. Lancet. 2017;389(10070):736-747. Available at
  5. Chou R. Low back pain. Ann Intern Med. 2021;174(8):ITC113-ITC128. Available at
  6. Downie A, Williams CM, Henschke N, et al. Red flags to screen for malignancy and fracture in patients with low back pain: systematic review. BMJ. 2013;347:f7095. Free full text
  7. Torre LA, Bray F, Siegel RL, et al. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87-108. Free full text
  8. US Preventive Services Task Force. Screening for lung cancer: US Preventive Services Task Force recommendation statement. JAMA. 2021;325(10):962-970. Free full text
  9. Mazzone PJ, Silvestri GA, Patel S, et al. Screening for lung cancer: CHEST Guideline and Expert Panel Report. Chest. 2018;153(4):954-985. Free full text
  10. Kertesz SG, McCullough MB, Darnall BD, et al. Promoting patient-centeredness in opioid deprescribing: a blueprint for de-implementation science. J Gen Intern Med. 2020;35(Suppl 3):972-977. Free full text
  11. Kroenke K, Alford DP, Argoff C, et al. Challenges with implementing the Centers for Disease Control and Prevention Opioid Guideline: a consensus panel report. Pain Med. 2019;20(4):724-735. Free full text
  12. Dowell D, Haegerich T, Chou R. No shortcuts to safer opioid prescribing. N Engl J Med. 2019;380(24):2285-2287. Free full text
  13. Committee on Diagnostic Error in Health Care, National Academies of Science, Engineering, and Medicine. Improving Diagnosis in Medicine. Washington, DC: National Academies Press; 2015. Free full text
  14. Graber ML, Franklin N, Gordon R. Diagnostic error in internal medicine. Arch Intern Med. 2005;165(13):1493-1499. Free full text
  15. Fedewa SA, Kazerooni EA, Studts JL, et al. State variation in low-dose computed tomography scanning for lung cancer screening in the United States. J Natl Cancer Inst. 2021;113(8):1044-1052. Free full text
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This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers