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Consultations and referrals


Improving the referral-consultation process

Content of the consultant's report


A consultant's report should be:
  • timely
    • consistent with the urgency
    • consider verbal notification of critical results
  • clear
    • answer the question(s) posed
    • state your conclusions and recommendations
    • document the rationale for your management recommendations
    • clarify who is responsible for investigations and further care
  • complete
    • document the history and physical findings that you obtained
    • include any additional relevant advice or recommendations (e.g. investigations, management, recommendations to consult others)

Case: Lack of follow-up after colonoscopy
Calendar

Background

A family physician refers a 52-year-old male to an endoscopist for investigation of an iron deficiency anemia and occult blood in the stools. A colonoscopy is performed. Visualization is achieved only to the level of the mid-transverse colon and the procedure is terminated due to patient discomfort. The patient is advised to follow up with the endoscopist, but no appointment is given.

Three weeks later, the endoscopist dictates a note stating his intention to arrange a barium enema to ensure there is no bleeding from the right side of the colon. The patient does not attend the follow-up as he had not received the appointment for the barium enema and he believes the endoscopist wanted the test done prior to seeing him.

The endoscopist presumes the patient had opted to follow up with the family physician and makes no further enquiries.

Calendar

Background continued

During an unrelated visit with his family physician six weeks later, the patient mentions that no date had been set for a follow-up with the consultant endoscopist. The doctor records the inadequacy of the colonoscopy and the recommendation for a barium enema, but assumes ordering it would be the responsibility of the consultant.

Seven months after the colonoscopy, the patient returns to his doctor complaining of cramping abdominal pain, and is referred to a general surgeon. A repeat colonoscopy reveals an obstructing and bleeding mass of the right colon; biopsy confirms adenocarcinoma. The patient undergoes a right hemicolectomy for a locally invasive cancer. After a course of chemotherapy, the patient develops a major depression requiring psychiatric care.

The patient starts a legal action alleging the seven-month delay in the diagnosis allowed the cancer to progress and metastasize to the lymph nodes.

Outcome

Experts were not supportive of the care given by either the family physician or the endoscopist:
  • Endoscopist expert: "...with the referral and subsequent follow-up to the incomplete colonoscopy, the onus of responsibility specific to investigations, including the barium enema, was the primary and direct responsibility of the consultant."
  • Family physician expert: "...the family physician owed a duty of responsibility, given the time frame of the test not being done, to ensure that this test had been requisitioned or to direct the patient to contact the consultant. Failure to pursue either option falls below the standard of care."

Lacking expert support, a settlement was paid to the patient by the CMPA on behalf of both member physicians.

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