PUBLIC DECLARATION REGARDING

SCRIPPS CLINIC, GREEN HOSPITAL, LA JOLLA, CALIFORNIA

Laura Walther Nathanson M.D., F. A. A. P.

PACKAGE 2A

008 -  012B

Summary:  You are likely to come across medical reports that are signed by a senior doctor, with a second line saying “dictated by” another doctor or medical student.

This does NOT mean that the senior doctor told the doctor-in-training what to dictate. It DOES mean that the doctor-in-training created the report and dictated it, and that the senior doctor had the duty to read the transcribed report critically and make any corrections or additions before signing it. 

The signature of the senior doctor is supposed to be awarded ONLY after that critical reading has been made. Whether, and how carefully, a critical reading has been made is often open to doubt.

For example:

The first document, 008, is Chuck’s admission report from January 31, 2000.  You will see that it is signed by Merri McMahon, Board Certified Cardiologist; but that it is dictated by Michael Lloyd, M.D., who was at that time a first year resident in Internal Medicine. That is, he had graduated and received his MD in June of 1999. eight months earlier. 

His discussion is very complete. 

In particular, Dr. Lloyd  makes clear the nature of the  “The most important question.”  He writes, at the bottom of Page 2, second paragraph under “PROBLEMS AND PLAN:”  “However, other more serious etiologies need to be ruled out. I feel a chest x-ray to rule out any obvious mass which is evidence against a malignant pericardial effusion.” 

In the end, Dr. Lloyd does not commit himself as to whether any obvious mass was noted. The sentence above, beginning “I feel a chest x-ray,” is without logic and meaning. When he refers to Dr. Goff’s reading, he does not mention the lungs at all; only the heart findings.

Clearly, this means that this doctor-in-training has not addressed the “more serious etiology” of malignancy. Yet Cardiologist Merri Mc Mahon signed off on this report without any corrections or suggestions.  

Four years later, Dr. McMahon received an “intent to sue” letter from my attorney. At that time, she didn’t recall having seen Chuck at all, ever.  Rather than check his medical record, Dr. McMahon had her secretary, Latisha Wade, leave an indignant voice mail (009 A) to this effect. My attorney had to remind her of the entire episode (009B).

Document 010 is Chuck’s discharge note from the same hospitalization. You will see that this note is signed by Board Certified Cardiologist Douglas Triffon, but that it is dictated by Farhad Shadan, M.D., Ph.D. Dr. Shadan was at that time, like Dr. Michael Lloyd, a resident in Internal Medicine.

Unlike Dr. Lloyd, Dr. Shadan does not consider malignancy at all. Dr. Shadan’s version of the possible causes of Chuck’s fluid around the heart consists of “idiopathic, viral syndrome, cardiovascular disease, and ischemia.” He does not even mention that a chest x-ray was performed. 

Clearly, this means that the whole topic of possible malignancy has been expunged.  However, this discharge note has been signed by Dr. Triffon with no corrections or suggestions.

We move on now to Chuck’s second encounter with Scripps Clinic, in November of 2001, twenty-two months later.

Document 011  is a reader-friendly summary of the disease Thymoma. You will note that Thymoma  is the most common tumor in the “anterior mediastinum,” the area of the chest above the heart. You will also note, under “Prognosis,” that Thymomas rarely metastasize outside the chest. Instead, they invade chest structures: one or the other lung, lung lining, and structures surrounding the heart. 

Document 012A is the first consultation with Chuck’s Pulmonologist, Jacqueline Chang, MD.  Dr. Chang notes that Chuck has a tumor in the right hilum (a portion of the anterior mediastinum) and right chest, that he was never exposed to asbestos, that he hadn’t smoked his pipe in twenty years. She does not include the fact, which we told her, that Chuck’s maternal grandmother died of Malignant Thymoma. Nonetheless, Dr. Chang produces a differential diagnosis that emphasizes one cancer (mesothelioma) that nearly always arises from asbestos exposure, and a second one (bronchogenic) mostly related to cigarette smoke. She does not mention the possibility of Thymoma.

Document 012B is from the department of Hematology/Oncology, and is a  “consultation . . . for Cancer of Unknown Primary Site.” You will note that there are no signatures to this report, but that it was dictated by Michael Hopkins, M.D., at that time a Resident in either Internal Medicine or Oncology—his online information has been deleted, apparently at his own request.  The senior physician, William E. Miller, is Board Certified—but only in Hematology, not Oncology. Chuck did not have a disease of the blood. 

You will note that the report is unsigned by either Dr. Hopkins or Dr. Miller. 

Dr. Hopkins makes no mention of a history of a right sided chest tumor documented 22 months earlier; no mention of the inadequacy of the biopsy specimen (see Package 4, 017).  He does mention of the CT reading (018)  on 11/18/2001, which gives Malignant Thymoma as a possible diagnosis. Needless to say, Dr. Hopkins shows no recognition that Chuck’s was a “textbook case” of Malignant Thymoma. 

It is unclear whether Dr. Miller read the report of Dr. Hopkins. If he did read it, as a Hematologist rather than as an Oncologist, he could well have failed to spot the oversights in the report. However, he certainly did understand the dire prognosis:  Dr. Miller refused to schedule a follow up visit for Chuck “until symptoms become unbearable,” because there was nothing he could do for Chuck and such a visit would therefore be a “waste of time.”

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