‘No News’ Is Rarely Good News in Medicine

Redundancy has its virtues — especially when it comes to making sure that imaging and other test results get back to a patient’s primary care physician.

A long-time patient of Dr. IM, an internist, had relevant history of a negative mammogram four years earlier and no breast cancer in the family.

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The woman saw Dr. IM on several occasions during the year following the mammogram and then resumed her visits after a three-year absence. During those visits, Dr. IM addressed the patient’s shoulder and knee complaints associated with osteoarthritis. During a January visit in which the 75-year-old patient reported improvement in her knee, Dr. IM ordered a screening mammogram. The patient made no complaints about her breasts and, per his custom, Dr. IM did not do a breast exam. Dr. IM filled out the breast referral and marked it urgent, which was also his usual practice.

The patient returned three times over the next three months. On the third visit, Dr. IM noted: “Patient had a mammogram and we did not receive results. Will try to contact to get mammogram results.” Despite that notation, there was no mention of the mammogram in Dr. IM’s notes for the patient’s six subsequent visits over the next six months.

During a hospitalization in December, the patient had surgery for pericardial fluid. A CT scan revealed pulmonary masses suspicious for metastasis, right breast masses, and skin thickening suggestive of breast malignancy. A right breast biopsy revealed a high-grade carcinoma.

After the patient’s hospitalization, her granddaughter came to Dr. IM’s office requesting the results of the mammogram done in January. Having not received the report earlier, Dr. IM’s office had the report delivered from the imaging center by fax that same day. According to the now one-year-old report, the patient showed a partially obscured suspect nodule of about 1 cm. The radiologist’s report suggested a right breast ultrasound.

Despite aggressive treatment in the five months following the discovery of the carcinoma, the patient died and her family sued Dr. IM for wrongful death. The family’s attorney contended that Dr. IM failed to timely follow up regarding the results of the patient’s mammogram and that these failures caused her death.

Investigation into the case revealed a certified letter sent by the imaging center to the patient in March indicating that the January mammogram was abnormal and that she needed to follow up with her personal physician.

Dr. IM and the family resolved the matter informally prior to arbitration.

With the increased use of electronic medical records in physicians’ offices, advanced systems of alerts and electronic reminders should make missed test results virtually a thing of the past. Until then, diligent use of “analogue” tickler and follow-up systems should be part of any office protocol.

 

Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc.(CAP).

 

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