Testes, a Tumor… and Two Negligent Physicians

Repurposed from The Scope, Second Quarter 2026

Initial Treatment

In August 2009, a 25-year-old male presented to his primary care physician (PCP) reporting a lump in his right testicle, which a sonogram confirmed as irregular and was suspected to be a tumor. The PCP referred the patient to the MLMIC-insured urologist for further evaluation.

Two months later, the MLMIC-insured urologist performed a right radical orchiectomy, and the patient was scheduled for a follow-up visit two weeks later. During this two-week period, a pathology review of the frozen section biopsied during the procedure resulted in a diagnosis of embryonal carcinoma. This diagnosis was not communicated to the patient, as the urologist intended to notify the patient of his diagnosis during the postoperative visit.

The patient missed the postoperative appointment, and the urologist did not follow up with the patient regarding this missed appointment or otherwise report the diagnosis to the patient. The referring PCP also remained unaware of the diagnosis.

Three months later, the patient visited his PCP for an upper respiratory infection. Blood work performed at the time indicated normal testosterone levels. Although the PCP knew the patient had an abnormality in his testicle during the last visit and had referred the patient to a urologist, there was no documentation that the PCP discussed the outcome of the urology visit. There was also no documentation showing that the PCP knew of or discussed the embryonal carcinoma diagnosis with the patient. This means that, three months after the diagnosis, the patient was still unaware of his condition, and no treatment plan was in place.

Diagnosis

The patient returned to the urologist on February 4, 2010, four months postoperatively. At this visit, the patient was finally informed of the diagnosis of embryonal cell cancer of the testes, and the urologist referred the patient to a radiation oncologist.

The patient was seen by the MLMIC-insured radiation oncologist on February 22, 2010. A CT scan of the chest, abdomen, and pelvis was ordered, and the surgical pathology was sent to a metropolitan medical center, which subsequently sent a consultation report to the urologist confirming the diagnosis of embryonal cancer.

 The CT scan ordered by the radiationoncologist showed nodules in the lungs that were believed to be inflammatory, but there was not significant evidence of metastatic disease. The radiation oncologist informed the patient of these results and advised him to follow up with the urologist for monitoring. There was no documentation thatthe radiationoncologist suggested that the patient consider other treatment options, such as examination by a medical oncologist.

The radiation oncologist contacted the urologist to advise that there was no indication for radiation therapy. Again, there was no documentation showing that the radiation oncologist suggested other potential treatment options to the urologist, including referral to a medical oncologist. The urologist also did not contact the patient to schedule a follow-up appointment, and there was no documentation indicating that he relayed the results to the PCP who had initially referred the patient.

The patient returned to his PCP seven months post diagnosis with complaints of inflamed breast tissue. Blood work done that day, and again one month later, returned as normal. A mammogram showed bilateral gynecomastia. There was no documentation indicating that the PCP considered further action related to these results. Instead, the patient’s last visit with the PCP was nine months post diagnosis, at which time he was tested for Lyme disease.

Patient Expires

Eleven months after the diagnosis of embryonal carcinoma, for which the patient was receiving no treatment, he presented to an internal medicine physician with complaints of extreme headaches for three weeks, tenderness in the right upper quadrant of his abdomen, and a lump in his chest. Lab work was ordered along with an MRI of the brain and CT scans of the chest, abdomen, and pelvis.

The following day, the patient presented to the emergency department of an urban medical center with worsening headaches, nausea, vomiting, and visual changes. After a battery of tests, the patient wasdiagnosed with metastases to the brain, chest, and abdomen. He started radiation therapy to the brain and was released home on September 23 with a plan for chemotherapy.

Two weeks later, the patient returned to the medical center, where it was determined that the cancer had continued to spread. The following day, the patient decided to return to his hometown, where he was admitted to a local hospital for pain. He was found to have metastatic disease throughout his body.

The patient remained at this hospital, where he received radiation and chemotherapy and was intubated and sedated, until his death one week later.

Lawsuit Filed

The decedent’s family filed suit against the MLMIC-insured urologist, the MLMIC-insured radiation oncologist, and the PCP. The family alleged that all defendants failed to provide proper monitoring and follow-up after the right radical orchiectomy. They also alleged that the defendants were negligent for failing to refer the decedent to a medical oncologist.

MLMIC consulting experts in urology, oncology, radiation oncology, and uro-oncology reviewed the case. Criticisms of the insured urologist included the failure to contact the decedent when he failed to return to the office for his scheduled postoperative visit and the failure to refer the decedent to a medical oncologist. Criticisms of the radiation oncologist included the failure to effectively communicate with the referring urologist regarding the diagnosis, including the need for consultation with a medical oncologist. The experts agreed that the breakdowns in communication between the physicians, and also between the urologist and the patient, led to the advancement of the disease and the death of the then 26-year-old male.

The parties agreed to forgo a trial, and mediation resulted in a significant settlement with contributions from the MLMIC-insured urologist and the codefendant PCP.

A Legal and Risk Management Analysis

Siloed Treatment

In this case, the 26-year-old patient died of a type of cancer that is highly treatable and usually curable if treated early. Unfortunately, none of the three physicians on his care team provided timely treatment. Had this matter gone to trial, rather than to mediation, the plaintiff’s counsel likely would have emphasized the multiple missed opportunities for referral and treatment that may have been avoided by communication and care planning. Rather than engaging in coordinated care, the physicians remained siloed in their own specialties and failed to communicate or jointly follow the patient’s condition.

There were several points at which this outcome may have been avoided had the physicians engaged in effective, coordinated care. The urologist, whohad knowledge of the patient’s critical diagnosis, failed to follow up with the patient to reschedule the two-week postoperative visit, or otherwise communicate the diagnosis to the patient, for over four months. The urologist also failed to report the critical diagnosis back to the referring PCP. When the patient saw the PCP three months post diagnosis, the PCP had no knowledge of the patient’s diagnosis and had failed to follow up with either him or the urologist for the initial condition of suspected testicular tumor.

More than four months post diagnosis, the urologist, after the radiation oncologist had reported to him and the patient that radiation therapy was not indicated, never followed up with the patient to discuss other potential treatments. The urologist also failed to provide the PCP with information from the radiation oncologist. The PCP saw the patient two more times but never discussed the status of his treatment with theurologist.

In summary, the role of the physicians in the patient’s care was not defined, and no physician took primary responsibility for the patient’s care. The physicians failed to employ patient and referral follow-up procedures as well as other risk management strategies that may have mitigated the inherent risks involved in multi-specialist care. For example, there should have been follow-up procedures in place for missed appointments. Whenever a patient fails to appear for an appointment, it is imperative that the medical facility contact the patient to explain the importance of the missed appointment as well as to determine the next course of action. Simple measures such as these can ensure that a missed appointment does not exacerbate the plaintiff’s condition.

Despite multiple physicians being involved in the patient’s care, the patient was never referred to a medical oncologist when the embryonal carcinoma diagnosis was confirmed. It appears that responsibility for referral to a medical oncologist was not clearly delineated by the three providers. Likewise, there was no communication between the providers to determine a course of treatment for the patient. As is evident from this case, errors in breakdown of communication can and do contribute to adverse and fatal outcomes.

Risk Management Takeaways

Having a Care Coordination System is Essential

Given the tremendous amount of information that may be involved in patient care coordination, practices must have a system(s) in place to track diagnostic testing and confirm that results are reviewed, communicated to the patient, and acted upon. Physicians and dentists should always consider whether the severity of the condition being treated requires phone calls between providers in addition to written reports.

Explicit Accountability Must Be Addressed

Care coordination processes should clearly identify who is responsible for the ongoing management of the patient, including following up with other providers to track and communicate a patient’s response to treatment. Avoiding assumptions avoids gaps in patient care.

Avoid Working in Silos

Effective management of a patient’s care includes ensuring that all care providers and staff share a common understanding of the care plan, including any adjustments made to the plan as circumstances warrant, and have access to the reports of the other providers.

For more complex or severe cases, treating physicians and dentists should consider implementing an “interprofessional huddle.” Had the radiation oncologist and urologist in the embryonal carcinoma case discussed the case beyond the singular question of whether radiation oncology was indicated, they may have considered next steps, including a referral to medical oncology. Similarly, a better outcome may have been possible had the surgeon and orthodontist spoken by phone rather than communicating through office personnel and emails.

A patient’s social determinants of health (e.g., income, education, housing, transportation, and food security challenges), which can help identify risk factors, are examples of the types of information that should be clearly communicated to and documented for all care providers.

Engage the Patient

Empowering your patients to be active members of their healthcare team is a crucial step to providing coordinated care. Engaged patients are more likely to adhere to treatment from multiple providers.

Recognize Patient Transitions as High-Risk

Patient discharge, specialist referrals, shift changes, and changes in care settings can lead to communication lapses. Practices should use established handoff processes to ensure care continuity, including the SBAR and IPASS protocols for transfers and handoffs, and the IDEAL model (AHRQ) for transitions back to home.

Documentation Should Reflect Coordination

As always, EHR documentation of what was communicated and when, and what follow-up is expected, is essential. Clear documentation supports continuity of care and enhances the defensibility of malpractice lawsuits.

MLMIC policyholders can reach out to our healthcare attorneys for questions about coordination of care or any other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here.

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This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.