A stubborn—yet seemingly-benign—cough leads to a lawsuit. Are you chasing symptoms or digging deeper?
Industry Buzz
When balancing over-testing vs missing a catastrophe, it’s important to ask what the consequences are if you are wrong.
—Pamela Tambini, MD
Persistent coughs are common, but when they don’t resolve, physicians must decide whether continued symptomatic treatment suffices or deeper investigation is warranted.
Misdiagnoses and delays in detecting serious pathology, including malignancy, remain a recognized risk.
Two pulmonologists were sued after a patient’s persistent cough masked liver cancer, a diagnosis they initially failed to consider. []
Though the physicians were not held liable, one question remains: How does a “benign” respiratory complaint harbor systemic or malignant disease?
The challenge for clinicians lies in knowing when to stop treating symptoms and when to escalate to deeper diagnostics.
Related: Top causes of medical malpracticeEpidemiology and risk
In adults, a cough lasting beyond eight weeks is typically considered chronic. []
Many patients initially labeled with “chronic cough” respond to standard therapies (eg, GERD treatment, inhalers), but a subset remains unresolved and merits further evaluation. []
In litigation literature, the delayed diagnosis of lung cancer after misattributing a cough is among the more frequent claims.
For example, one case settled for $1.5 million when a chest X-ray was delayed and lung cancer was diagnosed months later. []
When to escalate
“The biggest barrier to timely escalation is usually hesitation on the provider side driven by fear of over diagnosing or being dismissed by peers or higher-ups. Delays in systems and unclear thresholds can contribute to this also," says Pamela Tambini, MD, medical director at Engage Wellness.
Red flags of a chronic cough that require medical escalation include if it persists for more than eight weeks despite the patient receiving targeted therapy, and if the cough is accompanied by hemoptysis, weight loss, dyspnea, abnormal CXR, or smoking history, Dr. Tambini adds.
"These factors can trigger investigation of the lungs and chest by referral to a pulmonologist with chest imaging," says Dr. Tambini.
Red flags like a smoking history or abnormal lung sounds also lower the threshold, according to Annie DePasquale, MD, a board-certified family medicine physician.
The 2025 ARIA consensus on chronic cough warns that “red flag” symptoms should alert physicians to comorbid conditions such as tumors, cardiovascular disease, or severe infections. []
Authors of a review article in The Journal of Allergy and Clinical Immunology in Practice emphasize hemoptysis, weight loss, fever, or airway changes as markers for urgent escalation. []
If any of these signs occur, clinicians must shift from “watchful waiting” to targeted imaging and referral.
Related: Scans and symptoms screamed cancer—but it was something much more bizarreDiagnostic strategy
Initial (baseline) evaluation should include a detailed history and physical exam focusing on exposures, medications (eg, ACE inhibitors), and comorbidities. []
Chest radiograph and spirometry (pre- and post-bronchodilator) are required as a standard initial workup Empiric therapy should be avoided if the patient does not have any clear history of asthma, reflux disease, or nasal disease. []
However, if symptoms persist after 2 to 4 weeks of beginning therapy, reassess response and consider escalation.
Delayed lung cancer diagnosis is a well-known malpractice exposure. Failure to follow up on suspicious imaging (or misreading) is a frequent litigation theme. []
Courts often require evidence that an earlier diagnosis would have changed management or prognosis, making timely escalation and documentation crucial.
When red flags appear, or empiric therapy fails, proceed with CT chest (with contrast if needed), or HRCT to detect nodules, interstitial disease, mediastinal lesions, or airway abnormalities. If imaging suggests findings outside the lung (eg, liver lesions), consider cross-organ imaging or referral.
In cases with indeterminate findings or suspicion of extra-thoracic disease, engage pulmonology, oncology, GI, or hepatology as appropriate.
As part of surveillance, any incidental findings (eg, nodules) should be tracked with explicit follow-up plans (eg, Fleischner criteria).
Dr. Tambini acknowledges that the workup for chronic cough is a balancing act.
“When balancing over-testing vs missing a catastrophe, it’s important to ask what the consequences are if you are wrong," she says. "In cases of low-risk harm, we can watch and always re-check. In cases that have high risk or significant consequence, it’s important to escalate care with specialists or imaging.”