This case involves a sixty-two-year-old patient who was treated by a pulmonologist for chronic obstructive pulmonary disease (COPD). He had an eighty year history of smoking. The pulmonologist was treating his COPD with an ipratropium and albuterol combination formula. The patient began to experience shortness of breath and cough which produced small amounts of blood. The patient had a CT scan performed, which revealed several lung nodules. The radiologist recommended in a report, as well as verbally, a repeat CT scan in six months to monitor the patient for possible progression to cancer. The CT scan findings were disputed by the pulmonologist, who decided that he would be analyzing imaging studies of the patient moving forward. This was not communicated to the patient. The pulmonologist determined that a repeat CT scan was unnecessary based on his findings. Two years later, an additional CT scan was ordered, which revealed advanced lung cancer with significant metastatic disease. The patient was diagnosed with advanced small cell carcinoma of the lung with distant metastases. The patient had several rounds of chemotherapy with external beam radiation, but the patient died seven months after being diagnosed.