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A payment of $775,000 had been made on the gastroenterologist’s behalf to settle a civil malpractice action brought against him by a patient.

It was alleged the gastroenterologist failed to follow-up on pathology results that revealed cancer after he had performed a colonoscopy on the patient, which led to a delay in the diagnosis of colorectal cancer.

On 8/12/2009, a 55-year-old woman presented to a gastroenterologist with complaints of abdominal pain and rectal bleeding.  The patient’s medical history revealed a family history of colon cancer.  The gastroenterologist recommended that the patient have a diagnostic colonoscopy to evaluate her persistent rectal symptoms.

On 9/17/2009, the gastroenterologist performed a colonoscopy on the patient.  During the procedure, the gastroenterologist identified internal hemorrhoids associated with a sessile polyp in the mid-rectum.  The gastroenterologist removed the polyp and submitted the specimen for pathologic analysis.  The patient was discharged from the hospital on 9/17/2009.

On 9/18/2009, pathology diagnosed the polyp to be a moderately differentiated adenocarcinoma arising within a tubular adenoma.  On 10/6/2009, the gastroenterologist entered a progress note in the patient’s hospital chart directly documenting the finding of adenocarcinoma made in the pathology report.  Despite entering that chart note, the gastroenterologist never advised the patient of the finding of adenocarcinoma that had been made.

The gastroenterologist thereafter had no further contact with the patient until he saw her in his office on 8/23/2010, approximately eleven months after the colonoscopy had been performed.  At that visit, the gastroenterologist diagnosed the patient with hemorrhoids and prescribed steroid suppositories; however, he once again failed to inform her of the finding of cancer that had been made following the September 2009 colonoscopy.  Additionally, the gastroenterologist did not then recommend that the patient schedule a repeat colonoscopy.

The patient ultimately had a repeat colonoscopy performed by another physician on 4/27/2011.  Following that procedure, she was found to have an invasive carcinoma of the mid-rectum, and she commenced receiving treatment for colon cancer.

When appearing before the panel, the gastroenterologist testified that he was aware of the pathology findings that had been made following the colonoscopy but did not specifically advise the patient of those findings because he considered the pathology findings to be “benign.”  The gastroenterologist further testified that he was confident that he had removed the entirety of the rectal polyp at the time of the colonoscopy.  The gastroenterologist maintains that, after completing the colonoscopy, he advised the patient that she would need to see him again in “about” a year, but there is no documentation in either the gastroenterologist’s medical record or the hospital chart which memorializes respondent’s having advised the patient to have a repeat colonoscopy within one year.  Further, although the gastroenterologist entered a note in the patient’s hospital chart on 10/6/2009 documenting the pathology findings, he failed to record the pathology findings in his office medical record, and he failed to obtain and/or maintain a copy of the pathology report in his office record.

The Board judged the gastroenterologist’s conduct to have fallen below the standard of care given failure to document that he advised the patient to have a repeat colonoscopy performed within one year of the date on which the original colonoscopy was performed and failure to have documented the pathology findings of adenocarcinoma in his office record.

The Board assessed a fine against the gastroenterologist with stipulations to complete courses in medical record keeping and medical ethics.

State: New Jersey

Date: March 3017

Specialty: Gastroenterology

Symptom: Blood in Stool, Abdominal Pain

Diagnosis: Colon Cancer

Medical Error: Failure to follow up, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 3

Link to Original Case File: Download PDF

On 5/6/2013, a 55-year-old female presented to a digestive health center for a colonoscopy with biopsy.  During the colonoscopy, a gastroenterologist found a mass in the patient’s rectosigmoid region.  He obtained multiple biopsies of the mass and sent the specimens for in-house pathologic evaluation.  The colonoscopy was completed without complication and the patient was brought to recovery in stable condition.

On 5/7/2013, an in-house pathologist rendered a preliminary gastrointestinal pathology report which reported that the specimen was highly suspicious for a signet ring adenocarcinoma.  The initial pathology report indicated that the case was sent to a second pathologist for another opinion.

The gastroenterologist received and reviewed the initial pathology report.  He referred the patient to a colorectal surgeon for surgical intervention.

On 5/8/2013, the second pathologist issued a pathology report which stated that the specimen was negative for signet cells and adenocarcinoma and recommended a re-biopsy to completely rule out malignancy.  The gastroenterologist received and reviewed the copy of the report by the second pathologist.

On 5/16/2013, the in-house pathologist issued an amended gastrointestinal pathology report which stated that the specimen was negative for signet ring cells.  The gastroenterologist received and reviewed the amended pathology report.

Despite receiving and reviewing the pathology report from both the pathologists, the gastroenterologist failed to notify the patient of the change in the reading of the specimen.  The gastroenterologist also failed to ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

On 6/11/2013, the patient underwent a low anterior resection, mobilization of splenic flexure, and diverting loop ileostomy with colonic J pouch.

The Board judged the gastroenterologists conduct to be below the minimal standard of competence given that he failed to notify the patient of the change in the reading of the specimen and ensure that the colorectal surgeon was notified of the change in the reading of the specimen.

The Board issued a letter of concern against the gastroenterologist’s license.  The Board ordered that the gastroenterologist pay a fine of $10,000 against his license and pay reimbursement costs of a minimum of $3,008.71 and not to exceed $5,008.71.  The Board also ordered that the gastroenterologist complete five hours of continuing medical education in “risk management.”

State: Florida

Date: June 2017

Specialty: Gastroenterology

Symptom: Mass (Breast Mass, Lump, etc.)

Diagnosis: Cancer

Medical Error: Failure of communication with patient or patient relations, False positive, Failure of communication with other providers

Significant Outcome: N/A

Case Rating: 5

Link to Original Case File: Download PDF

On 6/22/2010, Gastroenterologist A provided a consultation for a patient after an abdominal ultrasound showed that the patient had cholelithiasis and choledocholithiasis.  The patient’s elevated liver enzymes and dilated bile duct indicated a moderate to high probability of the possibility of stones and warranted a preoperative ERCP and sphincterotomy.  The purpose of the consultation was to remove a suspected common bile duct stone prior to a cholecystectomy.

On 6/28/2010, Gastroenterologist A performed an ERCP with sphincterotomy and balloon sweeping of the common bile duct.  He was unable to determine if he had successfully removed the suspected common bile duct stone from the patient’s dilated bile duct and placed an 8.5-French 5 cm stent into the common bile duct.

In the patient’s chart, Gastroenterologist A noted: “will pull the stent out in 2 months.”

On 11/24/2010, Gastroenterologist A next saw the patient in his office.  A second ERCP was scheduled for 2/10/2011 to remove the stent.  The patient’s medical chart contains no record of instructions given to the patient or his family members regarding the removal of the stent.  The patient’s medical chart contains no explanation for the passage of time between the placement of the stent on 6/28/2010 and the removal of the stent on 2/10/2011.  The Board noted that stents can be expected to occlude after six months and form a nidus for the formation of other stones, mud, and debris.

At 8:30 a.m. on 2/10/2011, Gastroenterologist A performed a second ERCP on the patient and removed the stent.  During the second ERCP, Gastroenterologist A performed a balloon sweep.  The patient’s medical chart contains no clear documentation that all ducts were swept.  No antibiotics were prescribed or administered to the patient immediately before, during, or after the second ERCP.  After the second ERCP, the patient was discharged from the endoscopy facility.  Several hours later, the patient’s wife called Gastroenterologist A’s office to report that the patient was experiencing chills and pain in his back and stomach.  Gastroenterologist A and/or his staff advised that the patient should be brought to Gastroenterologist A’s office right away.

At 6:00 p.m., after efforts to convince the patient’s wife to bring the patient to his office had been unsuccessful, Gastroenterologist A noted in the patient’s chart that he advised the patient’s wife to bring the patient to the office the following morning if the pain were to continue.

Thereafter, Gastroenterologist A prescribed amoxicillin 500 mg to be taken three times a day for the patient.

The following morning, the patient’s condition had not improved.  Further conversations took place between Gastroenterologist A and/or his office staff and the patient’s wife.

At noon on 2/11/2011, the patient arrived at the hospital.

On 10/7/2014, Gastroenterologist A testified that there had been several telephone calls between his office and the patient’s wife on 2/10/2011 and 2/11/2011.  Further, he stated that he and/or his staff had impressed upon the patient’s wife the severity of the patient’s condition and that it was matter of life and death that the patient receive urgent medical attention, but that patient’s wife apparently failed to understand and/or take Gastroenterologist A’s comments seriously.

However, Gastroenterologist A did not document in the cart for the patient.  He did not document the frequency of the conversations, the information given to the patient’s wife, or his wife’s failure or refusal to understand the information.

At 1:30 p.m. on 2/11/2011, the patient was admitted to a hospital and was found to be critically ill with severe sepsis.

Gastroenterologist A consulted Gastroenterologist B, who performed an ERCP on the patient on 2/12/2011.  Gastroenterologist B found “clear evidence of a biliary obstruction as evidenced by darkly pigmented bile and extensive amounts of bloody liquid and sand-like material concerning for hemobilia.”  Gastroenterologist B diagnosed “biliary obstruction resulting in ascending cholangitis and sepsis” and placed a stent in the common bile duct.

On 2/12/2011, the patient passed away.

On 2/16/2011, Gastroenterologist A completed a two-page note in the patient’s medical chart entitled “Death Summary” and marked “Final Report, ” in which he made the following comments.

“Endoscopic retrograde cholangiopancreatography was performed 2 or 3 months ago … for common bile stone retrieval with stenting of the common bile duct … His condition continued to deteriorate.  During the night, his oxygen saturation began to deteriorate, suggesting acute respiratory distress syndrome.  He was intubated and put on the machine.  The blood pressure was kept on Dopamine and Neo-Synephrine.  But, in spite of this, on 2/12/2011 after all the resources have [sic] been pulled out, I have a hunch that he would not make it because of multiorgan [sic] failure.  Therefore, I called the family and explained the grave situation as best that I could.  The patient finally expired on 2/12/2011.”

Gastroenterologist A listed the final diagnosis as “septic shock, death.”

Gastroenterologist’s “Death Summary” for the patient contained no mention of the third ERCP, performed on 2/12/2011, or Gastroenterologist’s B diagnosis of biliary obstruction.

After a hearing, the State Medical Board concluded that Gastroenterologist A committed repeated negligent acts given failure to ensure timely removal of the temporary stent, failure to ensure that the patient had a clear understanding of the importance of timely removal of the temporary stent, failure to ensure that the patient had an understanding of the risks associated with performing the second ERCP and the possible warning signs to monitor after the procedure, and failure to maintain appropriate documentation of his care and treatment of the patient.

The State Medical Board placed Gastroenterologist A on probation with stipulations to complete a professionalism program, complete a medical record keeping course, complete 40 hours annually of continuing medical education for each year of probation, and undergo clinical practice monitoring with an emphasis on medical record keeping.  During probation, Gastroenterologist A was prohibited from performing ERCP procedures.

State: California

Date: May 2017

Specialty: Gastroenterology, Internal Medicine

Symptom: Fever

Diagnosis: Sepsis

Medical Error: Physician concern overridden, Delay in proper treatment, Failure of communication with patient or patient relations, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 4

Link to Original Case File: Download PDF

A 69-year-old male with diffuse systemic sclerosis, interstitial lung disease, end stage renal disease on hemodialysis, anemia, hypertension, hypoalbuminemia, secondary hypothyroidism, and gastric antral vascular ectasia (“GAVE”) had been referred to a gastroenterology clinic for evaluation of recurrent problems with weight loss and dysphagia.  It was assumed that the patient’s disease had progressed to esophageal scleroderma and that a percutaneous endoscopic gastrostomy (“PEG”) would be necessary to bypass his esophagus and would allow him to take in adequate nutrition without swallowing.  The patient was referred to the gastroenterology clinic for evaluation and a PEG.

On 6/25/2012, the gastroenterologist ordered a PEG, and she scheduled an esophagogastroduodenoscopy (“EGD” or upper endoscopy) and esophageal manometry for the afternoon of 6/25/2012, both elective, non-emergent diagnostic procedures, scheduled to be done on an outpatient basis.  On 6/23/2012 or 6/24/2012, the patient had been discharged from the hospital on antibiotics with home oxygen administration after treatment for aspiration pneumonia.

The gastroenterologist performed a pre-endoscopy history and physical examination in the early afternoon of 6/25/2012 and noted that the patient had active diffuse scleroderma complicated by renal crisis, diffuse systemic sclerosis, interstitial lung disease, GAVE with multiple cauterizations, and end stage kidney disease.  In past medical history, she listed “scleroderma renal crisis, “Started dialysis December 30, 2011,” and “Pneumonia. Admitted to er 6/24/12.”  She noted that the patient had had multiple upper endoscopies for gastrointestinal bleeding prior to this EGD.  Her physical examination listed “Lungs: Clear Auscultation. Clear percussion and Normal Symmetry and Expansion.”  She noted that she, not an anesthesiologist, was ordering sedation.

Sedation was to be administered by a registered nurse.  The gastroenterologist listed Airway as Class 2 and ASA Level (American Society of Anesthesiologists physical status classification system) as 3 (severe systemic disease).

On 6/25/2012 at 2:48 p.m. and ending at approximately 3:15 p.m., the gastroenterologist performed an upper endoscopy on the patient and took biopsies.  Nursing records indicate that sedation consisted of midazolam, 7 mg, administered over the 22 minutes; fentanyl, 175 mcg administered over the 22 minutes, and Cetacaine spray applied to the throat prior to the procedure.

The patient was transferred from the endoscopy procedure room to the recovery area under the care of a registered nurse.  The nurse noted that the patient was unresponsive to verbal and painful stimuli, with blood pressure 108/70, heart rate 86, and O2 saturation 89% on 2 liters delivered by nasal cannula.  A face mask was applied at 10 liters O2 and oxygen saturation went up to 97%.  When the gastroenterologist was notified, she ordered reversal medications: flumazenil 0.25 mg IVP over 15 seconds and Narcan 0.4 mg IVP at 3:40 p.m., and the patient was still unresponsive.  A second dose of flumazenil 0.25 mg IVP was given at 3:43 p.m., and the patient became responsive at 3:44 p.m.  Once the patient was responsive, the gastroenterologist performed the esophageal manometry procedure.  No time is entered in the medical record for this procedure although the gastroenterologist acknowledges that it was done and the results are recorded.

The gastroenterologist was later notified by nursing staff of concerns with the patient’s breath sounds, and the gastroenterologist noted stridor at 4:26 p.m.  She was notified at 5:19 p.m. that the patient’s oxygen saturation was 89% on 5 liters oxygen delivered by nasal cannula.  At 5:20 p.m., the gastroenterologist ordered a chest x-ray due to the inability to wean the patient off oxygen after the endoscopy.  A face mask was applied at 10 liters oxygen at 5:21 p.m., and oxygen saturation went up to 93%.  The chest x-ray indicated “a dense retrocardiac opacity and a left pleural effusion” and a “volume loss in the left lung with mild shift of the mediastinum towards the left.”

After the manometry procedure in the recovery room, the patient’s oxygen saturation was monitored, and when the oxygen saturation remained above 90% for 30 minutes on room air, the patient met endoscopy discharge criteria.  The patient was discharged home with instructions concerning any complications that might arise.

The gastroenterologist states that she arranged to admit the patient to the hospital, but the patient left against medical advice (AMA).  Neither notation of this nor a signed AMA release was found in the record.  Pathology results revealed gastritis and the manometry procedure revealed a condition consistent with esophageal scleroderma.

On 6/27/2012, the patient presented to the emergency department with shortness of breath and cough.  Chest x-ray showed new right lung patchy opacities, and the patient was cachectic.  He was admitted to the intensive care unit for treatment of pneumonia.  The admission diagnosis was “most likely persistent pneumonia, likely aspiration due to esophageal dysmotility.”  The patient failed to improve despite intensive hospital care.  Although the gastroenterologist had scheduled a PEG for 7/2/2012, it was decided that the patient would not go through with the procedure.  Instead, it was decided that the medical team would provide palliative care for the patient.

On 7/4/2012, the patient died with the cause of death listed as aspiration pneumonia due to esophageal dysmotility and end-stage scleroderma with severe malnutrition as a contributing factor.

The Board deemed the gastroenterologist’s conduct as falling below the standard of care for the following reasons:

1) The gastroenterologist failed to provide an accurate analysis of the patient’s suitability for the endoscopic and manometry procedures.

2) She classified the patient as an ASA Level 3, which denotes an individual with stable multiple system disease that limits daily activity without immediate danger of death.

3) At the time of the EGD and manometry done by the gastroenterologist, the patient had just been released from another hospital, where he had been treated for aspiration pneumonia and discharged on antibiotics and home oxygen.

4) By reason of the patient’s recent aspiration pneumonia and the necessity for home oxygen administration, his ongoing scleroderma renal crisis which necessitated hemodialysis, his persistent interstitial lung disease, and his frequent bleeding and cauterizations for GAVE, his condition was not stable, and elective procedures at this time were contraindicated.  The patient’s classification was clearly ASA level 4, which denotes an individual with severe, incapacitating disease, poorly controlled or end-stage, at risk for death due to organ failure.

5) The gastroenterologist failed to provide for an anesthesiology consultation, given the patient’s unstable and life-threatening condition, and instead elected to provide conscious sedation directed by the gastroenterologist and administered by a registered nurse.  The level of sedation administered to the patient during the upper endoscopy procedure was relatively large for an individual with so many co-morbid conditions, and an anesthesiologist or nurse anesthetist should have been in attendance.

6) Since both procedures were elective, the gastroenterologist failed to reschedule the procedures for a time when the patient was stable and able to tolerate conscious sedation directed by the gastroenterologist and administered by a nurse.

7) The patient had a very unstable post-procedure course in the recovery room.  He was unresponsive to verbal and painful stimuli and oxygen saturation was below 90%.  Reversal medications had to be administered before the patient became responsive.  When the patient became responsive, the gastroenterologist performed the esophageal manometry in the recovery room.  This procedure was unnecessary to determine the need for a PEG and further endangered the health of the patient.

8) The respondent approved sending the patient home with instructions after his oxygen saturation was above 93% for 30 minutes.  The patient was a very high-risk patient for elective procedures and had had a very unstable post-procedure course in the recovery room, including the development or exacerbation of pneumonia.  Under these circumstances, in conjunction with his numerous co-morbidities, it was unsafe to send the patient home.  There was no record found of the patient leaving the clinic AMA.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Hospitalist, Internal Medicine

Symptom: GI Symptoms (GERD, Abdominal Distention, Dysphagia), Cough, Shortness of Breath, Weight Loss

Diagnosis: Gastrointestinal Disease, Pneumonia, Pulmonary Disease

Medical Error: Unnecessary or excessive treatment or surgery, Failure of communication with other providers, Lack of proper documentation

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

On 11/17/2011, a 56-year-old female underwent a colonoscopy performed by a gastroenterologist.  The patient had undergone a bone marrow transplant for chronic lymphocytic leukemia.  After the procedure, the patient complained of nausea, vomiting, and epigastric pain.  An endoscopy was performed the prior day to rule out graft versus host disease or cytomegalovirus infection and the colonoscopy was a part of that procedure.

The gastroenterologist performed the coloscopy to the terminal ileum.  The patient was sedated with midazolam 8 mg IV, fentanyl 175 micrograms IV, and diphenhydramine 50 mg IV in divided doses as the patient exhibited any signs of discomfort.  Biopsies and cultures were obtained and submitted for evaluation.  Pathology results indicated apoptosis of the ileum and right colon, but negative findings for CMV.

During the course of the colonoscopic procedure, full sedation was not achieved.  The patient became drowsy, but she became fully awake during the procedure more than once, complained of pain, and asked that the procedure be stopped.  The gastroenterologist continued and completed the procedure despite the patient’s urgent requests.

The Board issued a public reprimand against the gastroenterologist.  Stipulations included continuing medical education in the topics of pre-operative patient evaluation, informed consent, sedation, and medical record keeping.

State: California

Date: May 2017

Specialty: Gastroenterology, Anesthesiology, Hematology

Symptom: Abdominal Pain, Nausea Or Vomiting

Diagnosis: Post-operative/Operative Complication, Hematological Disease

Medical Error: Procedural error

Significant Outcome: N/A

Case Rating: 1

Link to Original Case File: Download PDF

On 2/5/2015, a 50-year-old female underwent a colonoscopy conducted by a gastroenterologist.

Although the gastroenterologist noted a significant amount of liquid stool remaining in the bowel and hard stool adhering to mucosa, he continued the procedure and repeatedly injected saline and air into the bowel in an effort to clear the visual field.

Although the gastroenterologist knew that the suction button on the colonoscopy was continually sticking, thus making the necessary suctioning difficult and/or impossible, the gastroenterologist continued the procedure.

After approximately 31 minutes, the gastroenterologist stopped the procedure when he noted that the patient’s abdomen was distended.  He then ordered x-rays and requested an immediate surgical consultation.

The x-rays revealed free air in the abdomen.  The patient underwent emergency surgery to repair a baro-rupture of her cecum.  Subsequently, the patient developed sepsis and multi-organ failure and died on 2/12/2015.

The gastroenterologist was permanently restricted from performing invasive procedures.

State: Virginia

Date: April 2017

Specialty: Gastroenterology

Symptom: N/A

Diagnosis: Post-operative/Operative Complication, Acute Abdomen

Medical Error: Procedural error

Significant Outcome: Death

Case Rating: 5

Link to Original Case File: Download PDF

On 1/6/2010, an 84-year-old patient was admitted to the hospital with complaints of dizziness, anemia, and possible GI bleeding.  On 1/8/2010, a gastroenterologist provided a GI consultation for the patient. The gastroenterologist’s handwritten note on that date was cursory and lacking in detail without documenting a comprehensive history, comprehensive physical examination, and/or the gastroenterologist’s medical decision-making.  The gastroenterologist submitted billing for the consultation using CPT billing code 99223, which was not supported by the gastroenterologist’s documentation of the visit.

On 1/9/2010, the patient underwent a gastroscopy.  Small gastric natural ulcers and a bulbar duodenal ulcer, which was 2.5 cm in size, were identified and cauterized.  Sometime later in January 2010, the patient was readmitted to the hospital with complaints of nausea, vomiting, diarrhea, weakness, and interval decline in hemoglobin.  The patient underwent laboratory tests, which showed anemia with borderline iron deficiency.

On 1/27/2010, the patient underwent both a gastroscopy and a colonoscopy.  Small oozing angiodysplasias were found in the duodenum and were cauterized.  Small adenomatous polyps were excised from the distal colon. On 2/1/2010, the patient underwent a second colonoscopy due to concerns that pathology may have been missed due to suboptimal bowel preparation during the first examination.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed a medically unnecessary second colonoscopy on 2/1/2010 within days of an initial colonoscopy, his documentation was cursory and some of the physician’s handwritten notes were illegible, and he submitted billing using the CPT billing code 99223, which was not supported by the physician’s documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Dizziness, Diarrhea, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Weakness/Fatigue

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

Sometime in May 2009, a patient presented to a gastroenterologist with a history of sporadic rectal bleeding and chronic reflux-type complaints.  An index colonoscopy conducted on 5/7/2009 demonstrated predominantly left-sided colitis. The patient was treated with oral and topical mesalamine preparations.  Initially, the patient’s symptoms responded to the treatment, but then worsened several months later.

On 8/24/2009, the patient underwent a second colonoscopy.  The patient was prescribed oral budesonide to treat what was believed to be an extension of the colitis.  The patient continued to have ongoing symptoms. On 11/9/2009, the patient underwent a third colonoscopy, which showed reduced activity of disease.  On 1/8/2010, the patient underwent a gastroscopy and a fourth colonoscopy in order to determine the course of future treatment. The colitis was believed to be inactive, and the patient was continued on oral mesalamine preparations.  The patient’s increased bleeding was believed to be hemorrhoidal in origin, and internal hemorrhoids were cauterized. The biopsy from the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The patient had difficulty swallowing (dysphagia) and abdominal pain.  The patient underwent gastroscope on 2/15/2010, 3/25/2010, 5/20/2010, and 4/19/2011.  In each instance, biopsies from the gastric antrum and distal esophagus/gastroesophageal junction were obtained, and mild chronic inflammatory changes were observed.  In each instance, the gastroenterologist did not obtain biopsies from the esophageal body. Repeated esophageal dilutions were performed in order to alleviate dysphasia symptoms.  The gastroenterologist did not document the presence or absence of constricting pathology.

The patient underwent additional colonoscopies on 8/24/2010, 4/11/2011, and 12/7/2012.  The patient underwent additional gastroscopies on 12/30/2011, 4/3/2012, 9/21/2012, 1/11/2013, and 3/1/2013.  In each instance, biopsies form the distal esophagus demonstrated inflammatory changes without Barrett’s metaplasia.

The gastroenterologist maintained handwritten notes of each visit.  Some of the handwritten notes were not legible. The gastroenterologist consistently failed to note any assessment and/or plan based on the assessment.  The gastroenterologist consistently billed using CPT billing code 99213, in the absence of documenting any expanded problem focused history or medical examination or medical decision-making.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated colonoscopies and gastroscopies of the patient without medical indication or necessity, failed to maintain adequate and accurate medical records of his care and treatment of the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99213, which was not supported by the physician documentation of his care and treatment of the patient.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Bleeding, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Abdominal Pain

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: N/A

Case Rating: 2

Link to Original Case File: Download PDF

On 4/21/2010, a 58-year-old was admitted to the hospital with chest and abdominal pain, nausea, vomiting, and leukocytosis.  The patient was seen by a gastroenterologist for GI consultation.

On 4/29/2010, the patient underwent a gastroscopy, which revealed erosive esophagitis, Los Angeles grade B, and “small ulcers with overlying semi fresh blood” were cauterized.

On 5/21/2010, the patient was re-hospitalized with complaints of persistent abdominal pain.  On 5/28/2010, a second gastroscopy was performed. The ulcers that were previously found had resolved.  The gastroenterologist biopsied the gastric antrum. The reasons for doing so were not documented in the patient’s medical chart.  The patient continued to experience pain, but the medical records did not characterize the pain complaints.

On 6/2/2010, the patient underwent a colonoscopy.  It was unclear from the medical documentation whether the colonoscopy was performed on an urgent basis.  During the study, the gastroenterologist removed small, benign polyps. The gastroenterologist recommended a repeat colonoscopy due to suboptimal bowel preparation.

On 6/15/2010, the patient was hospitalized with complaints of nausea and vomiting.  On 6/19/2010, a third gastroscopy was performed and revealed mild esophagitis. Sometime in August 2010, the patient was hospitalized with complaints of abdominal pain, nausea, and vomiting.  On 8/11/2010, a fourth gastroscopy was performed, which the gastroenterologist interpreted as showing “extensive ulcerative esophagitis with multi foci of blood.”

On 5/24/2011, the patient underwent a fifth gastroscopy, which the gastroenterologist interpreted as showing esophagitis and numerous erosions or superficial ulceration in the lower stomach.  Also on this date, the patient underwent a second colonoscopy, and the gastroenterologist recommended a “follow-up colonoscopy after a more thorough prep.”

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated gastroscopic examinations of the patient without medical indication or necessity, failed to maintain adequate or accurate records regarding his care and treatment of the patient, and submitted billing for each hospital visit with the patient using CPT billing code 99233, or a complex evaluation, which was not supported by the gastroenterologist’s documentation of the visits.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Chest Pain, Nausea Or Vomiting, Abdominal Pain

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF

A 58-year-old had a history of diabetes and generalized atherosclerotic vascular disease.  On 12/18/2009, the patient underwent an outpatient colonoscopy to assess complaints of diarrhea and abdominal pain.  The study was interpreted to show mild colitis, but biopsies were normal.

On 2/10/2010, the patient complained of abdominal discomfort and reflux-type symptoms.  The patient underwent a gastroscopy with finding of mild esophagitis and gastritis. Following placement of a stent and initiation of anticoagulation therapy, the patient presented with GI bleeding with bloody stools and hemoglobin decline necessitating multiple transfusions.

On 3/15/2010, the patient underwent a second gastroscopy, which the gastroenterologist interpreted to show multiple bleeding gastric ulcers.  The gastroenterologist cauterized the bleeding gastric ulcers with a BICAP probe. The patient continued to have bloody stools.

On 3/18/2010, the patient underwent a second colonoscopy and a third gastroscopy.  The gastroenterologist again interpreted the gastroscopy to show hemorrhagic erosions, which he again cauterized.  The colonoscopy was technically inadequate due to retained blood and debris.

On 3/20/2010, the patient underwent a third colonoscopy.  The gastroenterologist interpreted a finding of sigmoid diverticulosis.  On 6/4/2010, the patient was re-hospitalized with complaints of nausea, vomiting, weakness, and dark stools.  The patient was receiving antiplatelet therapy following a vascular intervention. On 6/4/2010 or 6/5/2010, the patient was seen by the gastroenterologist for GI consultation.  The gastroenterologist’s dictated consultation note was cursory, making no mention of the patient’s complaints or contributory medications. The gastroenterologist billed for the consultation using CPT billing code 99254, indicating a Level 4 consultation, which was not documented in the gastroenterologist’s consultation note.

On 6/5/2010, the patient underwent a fourth gastroscopy.  The gastroenterologist, again, cauterized “hemorrhagic erosion with evidence of slow bleed.”  On 6/7/2010, the patient underwent a fourth colonoscopy due to concerns of a lower GI tract contribution to bleeding.  The patient was found out have internal hemorrhoids, which the gastroenterologist cauterized.

The Medical Board of California judged that the gastroenterologist’s conduct departed from the standard of care because he performed repeated upper and lower endoscopic examinations of the patient in the absence of important pathology to justify the repeat studies, failed to maintain adequate and accurate medical records of his care and treatment to the patient, and submitted billing for his care and treatment of the patient using the CPT billing code 99254, which was not supported by the physician’s documentation.

For this case and others, the Medical Board of California issued a public reprimand and ordered the gastroenterologist to complete an education course (at least 40 hours) and clinical training program equivalent to the Physician Assessment and Clinical Education Program offered at the University of California San Diego School of Medicine.

State: California

Date: February 2017

Specialty: Gastroenterology

Symptom: Diarrhea, Blood in Stool, GI Symptoms (GERD, Abdominal Distention, Dysphagia), Nausea Or Vomiting, Abdominal Pain, Weakness/Fatigue

Diagnosis: Gastrointestinal Disease

Medical Error: Unnecessary or excessive diagnostic tests, Lack of proper documentation

Significant Outcome: Hospital Bounce Back

Case Rating: 2

Link to Original Case File: Download PDF