Saturday, April 18, 2009

Whose Responsibility?

Kevin MD links to a post from Dr. Amy Tutuer about her father's unfortunate demise from lung cancer. He had presented with hemoptysis (coughing up blood) and an X-ray confirmed a giant lung mass, later confirmed to be a highly aggressive cancer. He died 8 weeks later. But that's just the beginning of the story. Apparently, 7 months earlier he had had a minor urologic procedure performed. As part of his pre-operative testing for the urology case, a chest x-ray had been ordered. This CXR demonstrated a mass, much smaller, which the radiologist commented on and suggested follow-up. All the doctors involved in his care assumed someone else would inform the patient. No one ever did.

Kevin Pho is predictably outraged:
An ordering physician always needs to take responsibility for the results of the test, even if it doesn't fall under his specialty.


I get it. Another overpaid proceduralist neglecting to take care of anything other than making sure the lucrative procedure gets done. But let's take a moment, shall we? Do we really believe that some urologist is going to be the one who coordinates the appropriate follow up for an abnormal chest X-ray? A urologist? God help us all if that's the honest solution.

As a surgeon, I send all my elective patients for pre-operative testing. This usually involves some combination of blood work, an EKG, and sometimes a chest X-ray. The determination of what is needed is often left up to the pre-testing center, the primary care doctor, and the anesthesiologists who will be doing the case. On the day of the surgery I glance through the chart, make sure everything is copacetic, and then we proceed. Sometimes the lab will call a few days prior to surgery with an abnormal value and I will look into it dutifully. I'll be honest; I don't pay much attention to a CXR report unless I'm specifically concerned about something beforehand (patient with COPD, hsitory of lung resection etc). Sometimes the official report on the CXR doesn't end up on my desk until a week after the procedure has already been done. But my name is on the CXR and I have to go through a pile of reports every couple of weeks. If anything jumps out, I will contact the PCP.

So who is responsible for an abnormality on a pre-operative CXR? What is a surgeon/orthopod/urologist supposed to do if they get a CXR report on their desk a few weeks after operating on someone (whom they barely remember) that states something along the lines of "right lower lobe mass, well circumscribed, 1.1 cm, clinical correlation/follow up images recommended"?

What about the DOCTOR who actually provided the expertise in reading the image? I know it's outlandish to expect a radiologist to (heaven forbid) actually interact with a patient over the telephone, but is it really that unreasonable to expect a specialist to follow up with the consequences of his/her determinations? If a family practice doc refers a patient to me for an abnormal mammogram and I see the patient and recommend a stereotactic biopsy, whose responsibility is it to make sure that biopsy gets done? Ought not the surgeon, the ostensible expert, assume the primary burden?

For some reason radiologists are immune to the usual expectations of physician responsibility. It must be nice to just have to dictate an addendum in your report about "follow up" and "clinical correlation" in order to exonerate you from all future culpability. A subtle liver or lung lesion gets passed off to the "ordering physician". Because you can't expect a radiologist to care about what happens to patients whom they have been consulted to provide radiologic expertise on, right? Right? Am I missing something here?

Someday, we will have a national data base of patient information via a centralized EMR and concerning lesions on routine screening films will get red flagged automatically. Until then, shouldn't we be able to trust that the physician who deems such lesions as "concerning" will be the one who is in the vanguard of doctors who make sure that said lesion is addressed properly?

23 comments:

WarmSocks said...

That is so sad.

And why I ask for a copy of all test results to be mailed to me. I can arrange follow-up myself if the ordering physician doesn't contact me about abnormal results.

Anonymous said...

the other thing that you didn't say is that virtually every imaging study that I get these days always says something about clinical correlation and further imaging recommended

HudsonMD said...

Jeff,
A very difficult situation. I try and avoid these situations as much as possible. I constantly get copies of CT's that i do not order that have a note on it to "fax to PCP" with abnormalities on them that are not in the realm of the specialists expertise. A couple of things that i demand are: 1. all my patients having surgery go through me for all pre-testing and clearance. 2. i expect all specialists to call me with anything that needs followed up. they all have me cell phone number or pager. If they do not do that, they never see another patient of mine. This fragmentation of health care that has developed over the years is dangerous. I am not sure why all of a sudden everyone is too busy to pick up a phone and talk to eachother

Joseph Sucher, MD FACS said...

I have come to respect you through your blog postings. Therefore I will humbly say that I respectfully disagree.

The ordering physician has the responsibility to review every test that he/she requests. ANY information is then relayed to the patient by that physician. Even using your analogy we can see that it will not hold water.

Let's use examples:
1. You do not expect the heme or chemistry lab to call the patient who is anemic, or hyperkalemic, or has an elevated creatinine.
2. You do not expect the cardiology lab to call the patient with an unexpected abnormal heart rhythm.

And the ultimate example:
3. You do not expect, nor want, the pathologist to call the patient that has an abnormality in the specimen that you excise.

I submit that your example of the family practice physician referring the patient for a breast mass to you is not the same as you ordering "a test". As you posted, you are the expert in management of breast pathology. The radiologist is acting as a technician only. I do not want to be a technician for these patients. I do not want my referring physicians to use me like a McDonald's and tell me what "test" they want.

Please reconsider your point. My arguments are submitted for debate. I respect you and your writing and appreciate the opportunity that you give by posting your insights and opinions.

Respectfully,

Joe

Frank Drackman said...

I "Ordered" X-rays for a good month after completing Internship and for 2 years after transfering from 1 military base to another... didn't matter that I was 2 timezones and 1000 miles away..

Joseph Sucher, MD FACS said...

Frank,

You are referring to a System problem. That is different than 'Who is responsible'.

That being said. From a patient safety perspective and quality issue, relying on any one single provider to ensure that something doesn't get missed will result in a certain amount of failures. So eventually you need to implement measures within a system of care that does not totally rely on the fallibility of individuals.

Please see:

NEJM Volume 295:1351-1355 December 9, 1976 Number 24; "Protocol-based computer reminders, the quality of care and the non-perfectability of man" - CJ McDonaldJFS

OHN said...

As a layperson, I would hope that whatever doctor ordered my (subsequent) abnormal test, would either have someone from his staff give my PCP a heads up, with a quick call or fax of the report in question, or even call me directly and request that I follow up with my PCP.

I have seen firsthand how reports can fall between the cracks of everyone "thinking" that someone else has handled the issue, when in fact nobody has.

Buckeye Surgeon said...

Joe-
I agree with you wholeheartedly that any test/exam ordered by a physician WITH INTENTION of diagnosis/treatment needs to be followed up/confirmed by the ORDERING physician. But this is definitionally a different scenario. Screening CXR's as part of pre-operative clearance protocols get rubber stamped with the name of whomever the doctor is who will be performing the procedure; in this case a urologist. No one is looking for anything in particular. It's a hoop to jump through to get cleared for surgery. So my stance is that the overwhelming onus of responsibility needs to fall on the shoulders of the radiologist. If the radiologist sees a concerning mass on a CXR and he notes that the indication for such CXR was "pre-op screening" then a flashing red light ought to be going off in his mind. Get on the phone; call the patient, call the ordering physician, call the primary care doctor.

All I'm saying is that it doesn't seem right that all a radiologist has to do is dictate a qualifying statement at the end of a report and he can wash his hands of any future culpability.

And if, as you say, the radiologist functions merely as a technician, then perhaps we need to revisit the issue of how we compensate the specialty of radiology.

Fantac-
Communication is key. In this era of overspecialization of health care, we lose track of the idea that someone needs to be a ringleader. Unfortunately that often falls on the shoulders of internists/family practice docs.

Aidian said...

This does seem, from my outsider and layman's perspective, to be a case where EVERYONE who touched this case should have been proactive.

I can think of a rough analogy (with far lower stakes) in my everyday work.

The task itself is irrelevant -- what is relevant is that frequently but irregularly a piece of information needs to get from my workplace to someone at a remote location. Despite this information's importance there's no clear line of responsibility for it.

What happens usually is that EVERYONE feels obligated to make sure it happens, and my call ends with "yeah, I got it, you're the sixth person to call."

Should we have a better procedure? Sure.

But since we don't, everyone involved takes responsibility to make sure this detail gets accomplished. I would expect nothing less of licensed medical professionals.

The fact is, I pay a lot of money to health care providers, and I would expect that everyone involved gives EVERY aspect of my case their serious, considered, and complete attention.

With the amount I pay for health care, there should never be any aspect of my case that is a routine hoop to jump through on auto pilot.

radinc said...

OK, radiologist here.

There are plenty of incidents like this in the casebooks. In all cases, juries and judges have found that the radiologist who reads the film is at that moment in time responsible for the care of the patient and must transfer that care properly if it's indicated.

This requires a phone call and documentation in the report. Simply dictating "followup necessary" is not adequate. Same as just dictating "ruptured aortic aneurysm" without a call to anyone would be inadequate.

In fact, missed or detected but improperly transferred care of lung cancer is the #2 cause for litigation against radiologists. (#1 "missed" breast cancer on mammo), so most radiologists are aware of this.

later
radinc

WarmSocks said...

@Aidian: If you pay a lot of money to your healthcare providers, then you are in the minority. Most people pay far more for insurance than they would pay out-of-pocket for their medical care ($12,000 for insurance, vs $200-500 for a couple doctor's visits). It's the MVA/sudden illness fear that keep people paying high premiums.

I usually only pay my doctor $20 - not a lot of money at all. My insurance provider pays another $67. So for $87 my doctor pays his office manager, receptionist, billing clerk, his nurse, his scribe, and himself. He determines what the problem MIGHT be, orders tests, takes time a few days later to review those tests and decide on appropriate treatment, has his nurse phone me... There's a LOT more involved than 15 minutes of one person's time. I don't feel that my doctor receives nearly enough money for the care he provides.

Sure, someone should have notified the patient in the scenario described. But patients can't assume that no news is good news. Ask for all test results, and do the follow-up yourself when they are way outside of normal.

Anonymous said...

Dr. Gawande tells a very similar story in his first book. "Complications." The patient was a medical student, and had to sue his hospital to get anyone to pay attention to the error. He didn't want to do it - but no one would listen.

None of us likes the malpractice problem in the U.S., but really - with great power comes great responsibility. Own up - do the right thing. Take responsibility.

Anonymous said...

I wonder if it would have made any difference even in short term survival at picking it up 7mos earlier, if it was already visible on cxr

Bianca Castafiore said...

As I am in the middle of preop and preregistration and all things "pre-" for surgery next week, let me add my small frustration as a patient:

Because this is the fifth major surgery in eight months, I'm a pro at these things now. I bring with me copies of all test results needed -- done within the requisite time period, reported to the doc(s) needing to know, etc.

But get this... at the level of the *hospital* process -- the nurse insists on REPEATING EVERYTHING(from now on, image spiraling health care costs as being completely *my* fault). Why?

"BECAUSE THE RESULTS WERE ABNORMAL."

Well, by God, repeating everything is going to cure that...

This same nurse is getting paid under the table to always have me kept in isolation, too, because LAST AUGUST, I tested positive for MRSA, which has since been successfully treated. Repeated tests demonstrate that I am debuggified. We ask for clarification, we complain, we even whine... but, you see, it's all right there in the chart --"Attention, Staph Staff, positive MRSA!"

Can't argue with a nurse with pursed lips, pointing at a piece of paper. In the preop holding area, I am assured they'll straighten it out with the floor --but still I wake to find everyone looking jaundiced in their snazzy yellow gowns.

The folks at this fine hospital *have* EMR.

Having the information, and knowing what to do with it? That would indeed be priceless.

Ah, I feel better now. Thanks!

Buckeye Surgeon said...

radinc-
Thanks.

Dr.T said...

Ya, you're missing something here. Namely, how medicine is practiced.

The radiologist is clearly responsible for assuring adequate communication of a significant finding to the referring physician.

If you were informed, you would know that this is standard of care and, actually mandatory, and been enforced in the courts many times.

Adequate communication may not have occured in this case, but that is anecdotal. The radiologist is at fault, as is the referring physician--I would even say the radiologist is more at fault because I am sympathetic to everything else you have said regarding your position as a referring physician.

However, the general attack on radiologists is counter-productive in this age, and it is wrong-headed in reality. This is your blog and it's your opinion and I come here as a guest and appreciate your sentiments; but as we face the unruly specter of Washington and the unGodly pressure of the misinformed public agitating change for change's sake in how we practice medicine, I do not find this kind of internecine war good for us.

Dr.T said...

"The radiologist is acting as a technician only."

--Joe Sucker MD FACS

Joe--

I respectfully submit that you misspoke(or mis-wrote?); however, if you would like to hash this out, I'd really like to match wits
with a FACS who believes that the interpretative medical science involved in diagnostic imaging is a "technologist's" job.

Is ten paces OK with you?

Joseph Sucher, MD FACS said...

Dr. T,

I will concede to simple inadequate wording. I agree with all of your points. My simplistic phraseology was not meant to be offensive, but certainly I can see that it is in retrospect. I attempted to distinguish that the radiologist in many cases never encounters the patient, but rather is interpreting a diagnostic study. This is in contradistinction to the role of the surgeon. I have great admiration for my radiologists, who's job of coming up with diagnoses based on grey-scale images without a history or physical exam is darn tough.

My point was that the care of the patient and the transfer of information to the patient is the responsibility of the surgeon, not the radiologist. The radiologist's limit of responsibility ends at the appropriate transfer of information to the ordering physician.

Thank you. My apologies.

JFS

Buckeye Surgeon said...

DrT-
Not a generalized attack on a specialty. (I love radiologists!) It's a very specific criticism of trend that I have found troubling. Recall that this post was prompted by a post on KevinMD that eviscerated the urologist who "ordered" the CXR.

I stand by my contention; the radiologist needs to do more on these cases where incidental findings are noted. They need to be held to a standard of accountability that includes pro-actively contacting either the patient or referring/ordering doctor. (radinc earlier point out that this is the expected standard of care.)

Anonymous said...

I used to love radiologists.
(and I have done this job longer than either buckeye or sucher)
Now In general, I find them to be rather prickish jerks who give me crap when I have the audacity to go down to the reading room to ask questions about MY PATIENT. If I hear " Have you looked at the report" in some snide tone, I am going to scream. I am sorry, but with the exception of IR, inhouse radiologists offer no more than telemedicine these days. I have dealt with nighthawks, the quality is the same and I can actually have a radiologist speak respectfully with an interest in the patient. What a novel concept. I miss the old (now retired) radiologists who actually clincal concern when I was in training. For to many years people have been going into this specialty for the $$$. It attracts some real assholes. This is one doc who looks forward to overseas telemedicine.

Dr.T said...

To the preceding "Anonymous":

Hahahahah....I'm glad I finally got around to rechecking this thread--Geez, I have to set this up so I'm informed by email when old fat cows come to graze on my land...

There is nothing more intellectually satisfying-- for erudite men -- than to see the anonymous confirmed as the mentally unbalanced and infantile--that's why they don't put their names on things.

Why don't you tell us who you are? Where do you practice? What's your specialty? Did you go to a Mexican medical school? Are you actually a quasi-professional? Or maybe your phimosis is showing?

I would like to discuss this with you--can you post again on this thread? Only this time, rather than act like a furtive adolescent wanker painting swastikas on the school door in the middle of the night, why don't you tell us who you are and what your bad auntie did to you to make you so...naughty?

Dr.T said...

To Dr. Buckeye and Dr. Sucher--

I think we all actually agree; and, it's a shame that the way things are laid out by the system (which is working everything into this great reform frenzy) we get set against each other. I really really despise that. I'd rather unionize and have you guys on my side and we all take a stand to make it right.

Hope this tardy post still reaches you all.

Jeffrey Segal, MD, JD said...

Here's a solution we have advocated for some time to keep an abnormal lab/X-ray from falling through the cracks. Tell the patient he will receive the lab results within X number of days. If you ordered the test, you assume this responsibility.

If the patient does not hear back from the office, the office visit is free. Now you have co-opted the patient's support to check his own labs. This time, though, his default assumption is NOT "no news is good news." His default assumption is that if he has not heard back, something fell through the cracks.

Incidentally, this is an old strategy. When I buy food from an airport vendor, the sign states that if I do not get a receipt, my meal is free. The owner of the store has co-opted my support in "guarding the register." It keeps the cleark from pocketing my money. And he did it without having to hire the guard.

Who has more skin in this game than the patient? No one. So, having the patient serve as his own safety net keeps him out of harm's way.