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Put the Patient in the Information Loop

This month, we feature an article from the archives written by CAP’s former General Counsel Gordon Ownby.

An abnormal test result typically sets in motion a number of follow-up actions by a patient’s treaters. While many of those actions will depend on the particular situation, one of them should be a constant: Telling the patient.

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A 51-year-old woman visited Dr. GS, a general surgeon, on a referral after an abnormal mammogram. The patient reported that her mother had a lumpectomy for breast cancer at age 65 and other family members experienced leukemia and bone, colon, and lung cancer. Dr. GS viewed the recent screening and diagnostic mammograms and noted marked density in both breasts with a particular 3 cm density on the lower right breast. An in-office ultrasound revealed a large dilated duct in the same area as the 3 cm density as well as multiple images consistent with cystic lesions. Dr. GS ordered an MRI and a colonoscopy and provided the patient with education and a care plan.

The patient returned three days later with a fever and right breast pain with streaking and redness. Dr. GS noted a swollen right breast with blotchy erythema and a hardened quadrant from 6-9 o’clock. Dr. GS’ working diagnosis was mastitis. Dr. GS started the patient on Keflex and dicloxacillin. The patient returned three days later, feeling better. Another ultrasound showed increased fluid collection. Dr. GS recommended the patient return in three to four days, at which time they would consider the previously recommended MRI.

When the patient returned two weeks later, Dr. GS’ nurse practitioner noted quadrants of mass-like hardening of the right breast and instructed the patient to now have her MRI, as the mastitis had improved.

The radiologist noted the MRI showed “multiple concerning lobulated enhancing masses localized in the lower inner quadrant...suspicious...directed ultrasound of area is needed. Ultrasound guided biopsy will be needed if lesions are identifiable. If not, MRI-guided biopsy will be recommended.” The radiology office sent the report to Dr. GS, but only told the patient of the need for follow-up studies.

Several days later, Dr. GS’ physician assistant sent an internal office memo to the front office staff asking if the patient had yet had the recommended biopsy. The front office told the PA that according to the radiology facility’s portal, the patient had an appointment for an ultrasound coming up. On the day after that scheduled (but failed) appointment, Dr. GS’ physician assistant initialed the original MRI report as read. No follow-up was scheduled. The radiology facility did not advise Dr. GS’ office of the failed appointment.

Approximately 30 months later, the patient had a new screening mammogram that revealed a new mass. An MRI and biopsy confirmed a malignancy in the right breast. The patient returned to Dr. GS, who noted a large palpable mass on the right breast but no enlargement in the nearby lymph nodes. Dr. GS recommended a mastectomy and ordered a PET scan to rule out metastasis. After the scan came back as negative, Dr. GS discussed several treatment options and ultimately scheduled the patient for a bilateral mastectomy. Dissection during the procedure found three positive lymph nodes out of 34.

Postoperatively, the patient complained of arm numbness, lymphedema, and decreased mobility in her arm. She had to stop chemotherapy because of severe side effects, but was able to undergo external beam radiation therapy. The patient’s suit against Dr. GS for medical negligence was resolved informally prior to a trial.

Dr. GS’ office’s attempt to track the patient’s pursuit of the recommended biopsy was likely handicapped by the patient’s ignorance of the matter’s urgency. The best “tickler” trails will be those that include telling a patient of an abnormal finding and explaining why further care is needed.