To the Editor:

“Documenting High-Risk Cases to Avoid Malpractice Liability” [October 2000, page 33] discussed the diseases commonly associated with malpractice litigation and highlighted five clinical situations where the risk associated with misdiagnosis is high. It was predictable that myocardial infarction would top the list and that three common cancers –colon, lung and breast – would be cited.

I’ll admit to being surprised to find acute appendicitis on the list, but this condition does have certain characteristics that can make it easy to miss. Simply put, the clinical picture may unfold gradually over hours to days, so establishing the diagnosis may require multiple examinations. A patient who has only vague symptoms and a soft, mildly tender abdomen when first seen may develop the full-blown picture later. It follows that the patient (or the parents, if the patient is a child) should receive specific instructions about what to do if the pain doesn’t go away in a few hours. This may require a return visit, a phone call to the on-call doctor or a trip to the emergency department, depending on the circumstances.

It is important to be aware of these clinical situations, but remember too that a primary determinant of malpractice suits is anger. Patients occasionally sue physicians they like and respect, but they’re much more likely to take action against those they perceive as uncaring or unwilling to listen. In the immortal words of the apocryphal sage S.K. Lapius, “Rude doctors are sued doctors.”