Cape Breton doctor reprimanded by provincial College of Physicians and Surgeons

A Cape Breton doctor has received a reprimand from the College of Physicians & Surgeons of Nova Scotia (CPSNS) following an investigation into his handling of a patient eventually diagnosed by another doctor with stage 4 lymphoma. 

In its decision published March 26, the CPSNS outlines the complaint against Dr. Venkata Karthik Rao Puppala. It was filed by a woman from Sydney on behalf of her son. 

Described as having “high-end autism,” the man in his mid-twenties had a cough and neck lump that wouldn’t go away. As he didn’t have a family doctor, the man’s neighbour (Puppala’s patient) asked if Puppala would see him. 

Following an initial appointment and examination in February 2021, the doctor noted a lump but suspected the man had asthma. Without any past medical history or records to refer to, Puppala gave him an inhaler with instructions to return if it didn’t help. 

When the patient’s condition hadn’t improved, the family friend brought the patient back to Puppala in early May 2021. Noting the patient’s hard lump and lymph node swelling on the side of his neck, Puppala ordered bloodwork and a CT scan, which took place in June 2021. 

Never told about CT scan results

Results of that CT scan and bloodwork were received by Puppala. The CT results showed what could be a sign of lymphoma.

“Dr. Puppala decided to act conservatively as he had seen numerous cases of enlarged lymph nodes in patients following their COVID vaccination and assumed the patient had received his vaccine,” the report said.

This was despite the fact the patient wasn’t vaccinated at that time. 

“The complainant states that if Dr. Puppala had used her son’s health card number (to search records) or asked any probing questions, it would have led to the discovery that her son had not been vaccinated, and at the time did not meet the necessary requirements for his age group to even be vaccinated,” noted the decision.

The family said they were never told about the June 2021 CT results, despite calling and asking for “almost a year.” Although the family friend who’d initially brought the patient to see Puppala had a number of appointments of his own during that time, he and the physician didn’t discuss the other patient or the CT scan results.

In November, 2021, the family friend brought the patient back to Puppala to get autism support forms filled out. The decision stated that neither the patient, family friend, nor his mother were aware of the CT scan results before that appointment.

“At that visit, the patient still had the lump in his neck and that, coupled with the results of the CT scan, prompted Dr. Puppala to order a biopsy,” the decision noted. 

Didn’t follow up

Unfortunately, the biopsy scheduled for Jan. 13, 2022 wasn’t performed because the patient didn’t go to his appointment. 

“Dr. Puppala did not follow up with the patient, the family friend or the patient’s mother about the missed appointment,” the decision said.

Puppala told the committee that in hindsight, he should have acted on the CT results and given the patient the option of doing the biopsy right away, or taking a “watch and wait” approach. He also said that he should have “further investigated” why the patient didn’t show up for the biopsy. 

Ultimately, the patient’s mother spoke with her own family doctor about her son, who was then diagnosed with stage 4 lymphoma. The decision noted that the mother believed Puppala didn’t read the report or follow up on it.

“He was more concerned with his burgeoning cosmetic surgery business to address the medical needs of his actual patients,” the mother is cited as saying in the decision.

In June 2022, the patient’s mother met with Puppala to inform him that her son had cancer. She mentioned that her own doctor was surprised the June 2021 CT scan that stated “lymphoma” hadn’t been followed up. 

“Dr. Puppala apologized for acting conservatively, thinking the lump could be vaccine related,” the decision said. “The complainant states if Dr. Puppala had told the family friend he thought the lump was vaccine related, they could have ruled that out, as the patient was not vaccinated.”

Although the written decision said it was unclear whether the family friend who attended the appointments knew of the patient’s vaccination status, “it appears no one was ever asked.”

‘Acknowledged shortcomings regarding patient’s care’

In his interview with the investigator, Puppala said he told the complainant, “We thought the lymph nodes went away, that’s why you missed your appointment.”

The committee said if Puppala didn’t see the missed appointment notification, it raised “communication and clinic operations concerns.” But if he saw the notification and then assumed the patient didn’t show up because he was doing better, “that assumption, coupled with not following up, was risky.”

In the decision, it was noted that the committee appreciated Puppala’s acknowledgement of his shortcomings regarding the patient’s care. 

“While it is to be commended that he agreed to help the patient via the family friend, this set-up was not without significant foreseeable risks,” it said. 

The decision also noted that while others were apparently inquiring about the patient’s health care concerns, Puppala stated no appointments were made by the man’s loved ones to discuss the patient at his office. He insisted his office promptly returned appointment request phone calls. 

“The Committee is satisfied that whatever was happening or not happening regarding the patient’s family attempting to make appointments, it was Dr. Puppala who should have reached out to follow up,” the decision said.

‘Could shake the public’s confidence in the practice of medicine’

It was determined that a reprimand was the appropriate sanction in Puppala’s case. 

In its decision, the CPSNS investigation committee noted that:

Dr. Puppala missed an opportunity to follow up with the family friend and the patient regarding the June 2021 CT that noted the lymphoma, and then failed to investigate why the patient did not show up for his January 2022 biopsy. These two instances contributed to the delay in the patient receiving his lymphoma diagnosis and associated treatment. 

The impact is significant. Dr. Puppala’s failure to proactively communicate back to the patient, a vulnerable person, and to the family friend and the complainant, could shake the public’s confidence in the practice of medicine because the expectation is that one’s treating physician will follow-up with you when a concerning test result is received, and ensure any follow-up testing is arranged and completed.

Four previous cautions

This wasn’t the first complaint against Puppala filed with the college. The decision notes four previous cautions (two in 2021, and one each in 2015 and 2017). Those cautions, the decision stressed, aren’t disciplinary sanctions, “nor is there proof of the underlying events leading to those Cautions.” 

“However, these Cautions make the misconduct in this case, if proven, more serious because Dr. Puppala was warned four times that his communication, record keeping, and integration of specialists’ care needed improvement,” noted the decision. 

“Despite these Cautions and despite having taken a Communications Skills training course, the problems persist, resulting in a delayed diagnosis for a patient who is not able to advocate for himself.”

As a result of Puppala having been previously warned to improve record keeping and communication skills, and to “appropriately manage a patient’s care” by integrating care from specialists — in this case, the opinion from the radiologist — the committee determined his “professional misconduct in this case” warranted the imposition of a licensing sanction.

Noting that lymphoma is a “significant illness with serious potential complications and outcomes,” the decision said the patient is relatively young, with “at a minimum, communication and self-advocacy issues, and noted to have ASD.”

“It appears Dr. Puppala did not follow up on this diagnosis to consider how it might impact the care he was providing to the patient,” noted the decision.

Findings

The CPSNS investigation committee found that Puppala failed to do the following:

• proactively follow up with a vulnerable patient and his family or caregivers in a timely fashion regarding a suspected lymphoma concern noted on a June, 2021 CT;
• investigate why a vulnerable patient did not show up for a scheduled biopsy in January, 2022 for a suspected lymphoma; and
• determine whether a patient has capacity to navigate their own care, and the capacity to consent to sharing their confidential health information with persons who are not substitute decision makers and who attend appointments as a support person or advocate, and to document same

As part of his reprimand, Puppala also agreed to pay costs in the amount of $2,500 as a contribution (not a fine) toward the costs of the investigation.

“All decisions remain permanently on the record of the College and can be referenced in the event of any future complaints made against the physician. Likewise, a Certificate of Professional Conduct will reflect all prior decisions,” the decision concluded.