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Should Serum Calcitonin Be Routinely Measured in Patients with Thyroid Nodules—Will the Law Answer before Endocrinologists Do?

University of California, Veterans Affairs Medical Center, San Diego, California 92161

Address correspondence to: Leonard J. Deftos, M.D., J.D., L.L.M., Department of Medicine, 3350 La Jolla Village Drive, San Diego, California 92161. E-mail: ljdeftos{at}ucsd.edu.

To the editor:

In addition to the studies reviewed by Hodak and Burman (1) in their editorial question about calcitonin measurements in patients with thyroid nodules, another recent JCEM study (2) has addressed the clinical aspects of the issue without providing an answer. But there is also a legal aspect of this issue that can be stated as follows: Is it medically negligent to omit calcitonin measurement in the evaluation of the patient with a thyroid nodule? Negligence can usually be defended against by demonstrating compliance with the standard of care. In many malpractice trials, the standard of care is that of the average practitioner of the class, and North American endocrinologists do not routinely measure calcitonin in the serum of patients with thyroid nodules (3). However, there is another standard of care in medical jurisprudence, the standard of reasonable care, which is finding increasing application in our courts (4). This standard was developed and applied by the Supreme Court of Washington in the case of Helling v. Carey (5). In that case, Barbara Helling sued two ophthalmologists for failure to diagnose glaucoma. When they tested her eye pressure at age 32 for the first time, she was diagnosed with glaucoma, which had greatly impaired her vision. Ophthalmology standards did not then require routine pressure tests for glaucoma for patients under 40 yr of age.

The medical-legal question at trial was whether the ophthalmologists’ compliance with their profession’s standard protected them from liability. While two lower courts said yes, the Washington Supreme Court said no. The Court’s reasoning could be used as an argument for measuring calcitonin in the serum of patients with thyroid nodules: "Although the incidence of glaucoma in the age range of the plaintiff is approximately one in 25,000, this alone should not be enough to deny her a claim. Where its presence can be detected by a simple, well-known [relatively inexpensive], harmless test, where the results of the test are definitive, where the disease can be successfully arrested by early detection, and where its effects are irreversible if undetected over a substantial period of time, liability should be imposed upon defendants even though they did not violate the standard existing within the profession of ophthalmology... . We therefore hold......that the reasonable standard that should have been followed......was the timely giving of this simple, harmless... ...test to this plaintiff and that, in failing to do so, the defendants were negligent... . "

The standard of care for thyroid nodules that has been established by thyroid disease experts and their professional associations does not include the measurement of serum calcitonin in North America, although it arguably does in Europe (3, 6). But what is reasonable care? Perhaps it would be prudent for endocrinologists to answer this question before the law does it for us?

Received February 18, 2004.

References

1. Hodak SP, Burman KD 2004 The calcitonin conundrum—is it time for routine measurement of serum calcitonin in patients with thyroid nodules. J Clin Endocrinol Metab 89:511–514[Free Full Text]
2. Elisei R, Bottici V, Luchetti F, Di Coscio G, Romei C, Grasso L, Miccoli P, Iacconi P, Basolo F, Pinchera A, Pacini F 2004 Impact of routine measurement of serum calcitonin on the diagnosis and outcome of medullary thyroid cancer: experience in 10,864 patients with nodular thyroid disorders. J Clin Endocrinol Metab 89:163–168[Abstract/Free Full Text]
3. Bonnema SJ, Bennedbaek FN, Ladenson PW, Hegedus L 2002 Management of the nontoxic multinodular goiter: a North American survey. J Clin Endocrinol Metab 87:112–117[Abstract/Free Full Text]
4. Peters PG 2000 The quiet demise of deference to custom: malpractice law at the millennium. Washington Lee Law Review 57:163–205
5. Helling v. Carey 1974 83 Wash. 2d 514
6. Bonnema SJ, Bennedbaek FN, Wiersinga WM, Hegedus L 2000 Management of the nontoxic multinodular goitre: a European questionnaire study. Clin Endocrinol (Oxf) 53:5–12[CrossRef][Medline]

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