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Diagnostic tips


Reducing medical-legal difficulties

Follow-up of patients


Female physician at desk speaking with elderly female patient

Case: Failure to follow up a patient following an MRI
MRI image of liver

Background

A 47-year-old businessman, with a recently diagnosed large liver mass, is referred to a gastroenterologist.

Physical examination is unremarkable. The gastroenterologist informs the patient the mass is probably a hemangioma and does not generally require any particular treatment.

Nevertheless, the physician sends the patient for an MRI and blood work, instructing the patient to return when he has completed the tests.

Background continued

A 47-year-old businessman, with a recently diagnosed large liver mass, is referred to a gastroenterologist.

Physical examination is unremarkable. The gastroenterologist informs the patient the mass is probably a hemangioma and does not generally require any particular treatment.

Nevertheless, the physician sends the patient for an MRI and blood work, instructing the patient to return when he has completed the tests.

Outcome

The gastroenterologist does not contact the patient as he is certain the patient will follow up, having been instructed to do so.

Nine months later the patient is diagnosed with pancreatic cancer and liver metastasis.

Think about it

How might this delay in diagnosis have been prevented?

Lessons learned

  • The more serious the abnormality and possible consequences on the patient's health, the more urgent it is for the physician who is aware of the result to take action.
  • It may be appropriate to directly contact the ordering/referring physician if a critical or unexpected result is found.
  • Physicians ordering investigations have a duty to communicate the results to the patient and to make reasonable efforts to ensure appropriate follow-up is arranged.
  • If applicable, provide information to the consultant from whom you sought advice.
  • Provide the information to the referring physician. (In this case the gastroenterologist failed to contact the patient).
  • As a student, notify your supervisor of abnormal test results.
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Case: An investigation for anemia
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, however, the procedure is terminated due to patient discomfort. Visualization is achieved only to the level of the mid-transverse colon.

The patient is advised to follow up with the endoscopist, but no appointment is given.

Three weeks later, the endoscopist dictates a consultation note stating "a barium enema will need to be arranged to rule out a lesion in the right colon."

The patient does not receive the appointment for the barium enema and does not follow up with the endoscopist. He believes the endoscopist wanted the test done prior to seeing him.

Background continued

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, however, the procedure is terminated due to patient discomfort. Visualization is achieved only to the level of the mid-transverse colon.

The patient is advised to follow up with the endoscopist, but no appointment is given.

Three weeks later, the endoscopist dictates a consultation note stating "a barium enema will need to be arranged to rule out a lesion in the right colon."

The patient does not receive the appointment for the barium enema and does not follow up with the endoscopist. He believes the endoscopist wanted the test done prior to seeing him.

Think about it

  • How could this delay in diagnosis have been prevented?

Outcome

Experts who were subsequently asked to comment on this case were not supportive of the care given by either the family physician or the endoscopist:
  • Endoscopist expert: "...with the referral and subsequent 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."

The legal action was settled on behalf of both the family physician and the endoscopist.

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Male physician with prescription pad

Discharge instructions, monitoring, and patient follow-up

When discharging a patient ask yourself:
  • Have you informed the patient of the possible diagnosis or differential diagnosis, and the need and process for follow up?
  • Have you explained the clinical situation to the patient?
    • Be objective and accurate.
    • Don't make broad statements without good support.
    • If unsure, state the diagnosis is not yet determined.
  • Have you given the patient discharge instructions that include potential symptoms and signs of a complication, the urgency of seeking additional care and where to find that care?
    • It is generally useful to check that the patient appears to understand what you have conveyed and to address any questions, to involve family members if permitted by the patient, and to consider providing educational handouts.
    • The patient should feel welcome to return for re-evaluation.
  • Is a system in place to facilitate timely follow-up of investigations and patients?
  • If you aren't sure about the clinical situation, let the patient know. Don't speculate, but rather wait for more information. Consider whether a consultation would be helpful.
  • Have arrangements been made for appropriate follow-up and, if warranted, referrals to other healthcare resources?
  • Has follow-up of the investigative plan been adequate, and do you have a clear understanding of who will be the most responsible physician for the ongoing management of the patient?
  • Should the attending physician be notified of the patient's condition?
  • At follow-up visits, should the assumed diagnosis be questioned? Are there new symptoms or signs? Is the patient's progress as expected given the clinical management?
  • Has the transfer of care and delineation of responsibilities been communicated to all relevant parties, and documented in the medical record?

For more information see informed discharge.

Referral and consultation if the diagnosis is unclear

If the diagnosis is unclear, ask yourself:
  • Is referral to an appropriate consultant necessary to help establish a diagnosis?
  • Have you referred the patient in a timely fashion? (It may be necessary to contact the consultant directly if warranted by the patient's clinical situation.)
  • Have you provided the consultant with sufficient information?
  • As a consultant, have you taken the appropriate history, performed a physical exam, and ordered the appropriate additional investigations? Have you provided a timely consultation letter to the referring physician?
  • Are the follow-up plans, and roles and responsibilities of each physician clear to both the physicians and the patient?

For more information see consultations and referrals.