23 April 2009

Piling on

In response to Kevin's post about a missed chest x-ray finding, Buckeye Surgeon takes exceptio0n to the idea that the ordering doctor is responsible for following up the findings:
Do we really believe that some urologist is going to be the one who coordinates the appropriate follow up for an abnormal chest X-ray? A urologist? God help us all if that's the honest solution.

As a surgeon, I send all my elective patients for pre-operative testing. This usually involves some combination of blood work, an EKG, and sometimes a chest X-ray. The determination of what is needed is often left up to the pre-testing center, the primary care doctor, and the anesthesiologists who will be doing the case. On the day of the surgery I glance through the chart, make sure everything is copacetic, and then we proceed. Sometimes the lab will call a few days prior to surgery with an abnormal value and I will look into it dutifully. I'll be honest; I don't pay much attention to a CXR report unless I'm specifically concerned about something beforehand.
I hate to say it, since I respect ol' Buckeye, but I'm with Kevin on this: you order the test, you own the results.

I deal with this all the time in the ER, and it's as annoying there as it is anywhere else.  I get the CT chest to rule out a PE, or the CT head for a blunt head injury, and it comes back negative.

Negative, except for some little incidental finding that's probably nothing, may be something benign, or very unlikely may be cancer or something bad.  Now I don't really care about this distl: it's not related to the reason I ordered the test, it certainly doesn't impact my care for the patient, and I am certainly not going to follow it up myself.  So what do I do?

For me, I've got the patient in front of me.  So I tell the patient.  That's always a fun conversation -- your chest x-ray was fine, but you might have cancer, and you should have your regular doctor check it out! I'm more diplomatic that that by a lot, but that's what patients hear, no matter how delicately I phrase it.   You can imagine how quickly their anxiety-mediated chest pain comes back after that conversation!

Seriously, though, that's the obligation that comes with the territory.  It's silly to expect the radiologist to inform the patient they have never seen or spoken to, just as the pathologist doesn't call the patient with their pathology results.   I also document my conversation with the patient, write the results down on their discharge instructions, and, if it's worrisome at all, I send a note or a voice mail to the PCP so it doesn't get lost.

I can see why it would be harder for a surgeon, since the patient may not be around when they get the results, and that may be well before or after the procedure.  Still, they have it easier since nearly all of their patients have a referring doctor or a primary care doctor that you can turf the work-up to.  How hard is it to send an email, fax, voice mail, or dictation?  Or to make a note in the chart and tell your secretary to make sure a letter is sent?  Lots of options there.

It's a pain in the ass to do stuff right, and it's really tempting to cut corners.  I get it.  But still: you order the test, you own the result.

1 comment:

ERP said...

One of my colleagues was sued for an incidental nodule on a CXR he ordered for trauma that a year later turned out to be cancer and the guy ended up dying. Luckily for my colleague, he documented that he had a conversation with the patient about the nodule and referred him to a pulmonologist. The guy did not follow up for almost a year when he began to have haemoptysis and by then he was toast. The case was thrown out of court because the judge felt my colleague's obligation to instruct the patient on the findings had been fulfilled.