Moderator: You are listening to the CMPA Educational Podcast Network. These learning materials are for general educational purposes only and are not intended to provide professional, medical or legal advice, nor to constitute a standard of care for Canadian health providers.
Dr. Steven Bellemare: Welcome to the CMPA’s podcast on the follow-up of test results. I’m Dr. Steven Bellemare, Senior Physician Advisor in Practice Improvement. This podcast will provide a detailed discussion of your professional and medical-legal responsibilities with regards to the follow-up of test results.Joining me today in studio is Dr. Marie-Pierre Carpentier, an Emergency Physician and a colleague of mine at the CMPA. Welcome Marie-Pierre.
Dr. Marie-Pierre Carpentier: Hi Steven, it’s a pleasure to be here today.
Dr. Steven Bellemare: Now Marie-Pierre, I understand that as a physician advisor at the CMPA, you’re often asked about issues regarding the follow-up of test results. Am I right?
Dr. Marie-Pierre Carpentier: Yeah, we do get many questions on that topic.
Dr. Steven Bellemare: So you must have had the opportunity to discuss that matter with the CMPA’s legal counsel?
Dr. Marie-Pierre Carpentier: Yeah, for sure. I spoke with Ms. Adriana Cargnello, who’s a partner at Gowling WLG. She’s been involved in many CMPA cases involving the follow-up of test results. She had a lot of great information about professional and legal responsibilities regarding this process.
Dr. Steven Bellemare: And so what did Ms. Cargnello have to say?
Dr. Marie-Pierre Carpentier: I asked her what the key messages our members should be focused on regarding the follow-up of test results are. Here’s what she had to say:
Adriana Cargnello: To follow up on test results, they need to have a system in place. To help them do that, the systems should be clear and simple and easy to follow. They need to document, while any efforts made to communicate with patients, and good and clear communication with patients, is always key.
Dr. Steven Bellemare: Well that seems manageable enough. I would think most members would follow these principles.
Dr. Marie-Pierre Carpentier: Yeah, I agree, but many physicians are often overwhelmed or discouraged and they don’t know where to start.
Adriana Cargnello: Well, one place to start is to know all the policies and guidelines. You can start by Colleges, professional associations, and also, if you’re working in a hospital setting, know the hospital policies. It’s also important to communicate well and clearly with patients. They need to understand what test is being ordered, why it’s important, and what steps they may need to take afterwards. It’s important to have a system. The system must allow the physician to ensure that test results are received, are reviewed, and acted upon in a timely and appropriate way for the issue at hand. Keep the system clear and simple. Build in redundancies, if possible. “No news is good news” is not a system. And it should only be used if the physician is confident that the test management system in place is robust so that no news really does mean good news.
Dr. Steven Bellemare: Well that’s very interesting. So if I can summarize what I think I heard her say, it’s essentially that having a “no news is good news” approach isn’t actually a follow-up system at all.
Dr. Marie-Pierre Carpentier: You’re right, Steven. That approach does not promote safe medical care. Let’s hear a bit more on that subject.
Adriana Cargnello: Document. Document that something has been read and by whom. Document attempts to contact the patient, document all communications and discussions with the patient. Train your staff. Make expectations clear. They need to know that the system is there, that they need to understand the system and why it is important. It’s not just an administrative task without consequences. And finally, if there is a problem with the system, don’t ignore it. Fix it. And if you’re working in a hospital setting, work with hospital staff and your colleagues to improve the system.
Dr. Marie-Pierre Carpentier: So being proactive and making sure your system is simple and effective is the best solution to improve patient safety and for your own peace of mind as a doctor.
Dr. Steven Bellemare: Marie-Pierre, you mentioned patient safety and that makes me wonder, do patients have a role or any responsibilities in following up their own test results?
Dr. Marie-Pierre Carpentier: In fact, Steven, I asked Ms. Cargnello that very question.
Adriana Cargnello: It’s quite clear that patients do not generally have a responsibility to actively follow up on test results. In other words, they don’t have a responsibility to track down their own test results. It can be that a patient may hold some responsibility and even some shared liability, but usually this does not exonerate the physician from his or her own duty to ensure follow-up of test results. It has to be made clear to a patient what the nature of the test is, its importance and what steps the patient needs to take. And in that case when it’s quite clear, it may be that the patient who chooses not to follow those steps may share in some liability. Communication with the patient is key, and documenting all discussions and attempts to contact the patient are also key.
Dr. Marie-Pierre Carpentier: You know, as a physician advisor at the CMPA, I’m often asked by our members what is considered a reasonable effort. The Colleges have clear guidelines concerning the follow-up of test results, but what is a reasonable effort? On that subject, let’s listen to Ms. Cargnello.
Adriana Cargnello: Well, when looking at what a reasonable effort is in a given situation, the courts and Colleges will look at the specific patient and that particular patient’s circumstances. The efforts will depend on the urgency of the situation and the risks and potential consequences.
Dr. Steven Bellemare: That makes a lot of sense, Marie-Pierre. But what if a patient misses their follow-up appointment, even on multiple occasions?
Dr. Marie-Pierre Carpentier: Yeah, Steven, the situation can be difficult, but the physician still has a responsibility. When we spoke, this is what Ms. Cargnello had to say on this issue.
Adriana Cargnello: Just because a patient is a no-show doesn’t mean the physician’s duty ends. There are reasonable efforts that need to be made to contact the patient and reschedule an appointment. And what is a reasonable effort will depend on the circumstances, specifically the urgency and risk to the patient. Reasonable efforts may extend to attempts to reschedule, even if the patient has cancelled more than one appointment. It is key to communicate well with the patient from the outset on the significance of the test and why it is being ordered. It is important to document all communications and efforts to contact the patient.
Dr. Steven Bellemare: Marie-Pierre, can you tell me what happens when there are multiple healthcare professionals involved in a patient’s care?
Dr. Marie-Pierre Carpentier: Well, Steven, more often than not, several players are involved in the follow-up of test results and sometimes this leads to multiple gaps in the process. The question is where does the responsibility lie?
Adriana Cargnello: Often, there are various healthcare professionals who can be involved in the collection and execution and reporting of test results. For example, we’ll have an ordering or referring physician, a reporting physician if that’s the case, depending on the test result, the lab and its staff, the hospital and its staff, a nurse, and even sometimes but more rarely, the patient. This can lead to situations of potential shared liability and shared responsibility between each of these parties and providers. But generally, the ordering physician is very rarely relieved of his or her personal duty to follow up. An example of perhaps where there may be a transfer of that duty to another healthcare provider would be, for instance, in the emergency room, an emergency room physician requests a scan. The patient is admitted, and the ER physician asks that the hospitalist follow up on the result. The hospital agrees to follow up on the results. There is a clear discussion between the two physicians and that discussion is charted clearly. Then in that case, there might be a situation where the duty transfers from the emergency physician to the hospitalist.
Dr. Marie-Pierre Carpentier: As you heard, there are many factors that come into play.
Dr. Steven Bellemare: So in a nutshell, Marie-Pierre, what would you say are the professional and legal obligations of a physician to follow up on test results?
Dr. Marie-Pierre Carpentier: Well, Steven, I suggest we listen to this very good summary from Ms. Cargnello.
Adriana Cargnello: The courts have long recognized the physician’s ethical and legal duty to follow up on test results. Colleges also expect physicians to follow up on test results and investigations. Some Colleges have issued specific policies and guidelines on the issue. In order to determine the nature and extent of the duty in a particular circumstance, the courts will look to College guidelines and policies, professional associations’ guidelines, hospital policies, and even expert opinion.
Dr. Marie-Pierre Carpentier: We also know that over 90 percent of College complaints have an unfavourable outcome for the physicians when it comes to the follow-up of test results. Also, it is important to remember the impact that a lack of follow-up may have on the patient. So it’s important for all of us as physicians to make sure that the follow-up of test results is a priority.
Dr. Steven Bellemare: Well thanks very much, Marie-Pierre. The good news, it seems, is that physicians do have control over this process. Making simple changes to our everyday practice can in fact improve our follow-up strategies and therefore improve patient safety. So if I can summarize, the courts and Colleges have clear expectations on our duty to follow-up test results, and so it’s up to us as physicians to make sure that we’re aware of our professional standards.
Dr. Marie-Pierre Carpentier: Exactly, Steven. It’s important to remember that teamwork and communication are key. It’s also very clear that you should have a system in place for the follow-up of test results. I’d like to reassure listeners that their system does not have to be perfect from the get-go. When I talked to doctors, most of them already know what the problem is with regards to the follow-up of their test results. Start with the issues that keep you up at night, fix them, and grow your system from there.
Dr. Steven Bellemare: That sounds like excellent advice. One thing that I might add is to make sure that your patients understand why you’re asking for a specific test, and that they also understand the importance of showing up for that test and ensuring that they receive the results.
Dr. Marie-Pierre Carpentier: I agree, Steven. And lastly, I just want to remind you to document clearly, all the efforts that you’ve made to reach the patient and to follow-up on that test result.
Dr. Steven Bellemare: Well, Marie-Pierre, thank you very much for joining us today. Unfortunately, this is all the time we have for this podcast. So on behalf of the CMPA, I would like to thank you, our listeners, for being here today. And until next time, I remain your host, Dr. Steven Bellemare.
Moderator: You are listening to the CMPA Education Podcast Network. These learning materials are for general educational purposes only and are not intended to provide professional, medical or legal advice, nor to constitute a standard of care for Canadian healthcare providers. The CMPA offers a series of workshops on following-up on test results. Visit our website, www.cmpa-acpm.ca, to register for the next one near you. Thank you for listening to the CMPA Education Podcast Network.