Matt (pictured on the left) is, thankfully, still alive. A year ago, he was diagnosed with aggressive prostate cancer and was rushed into life-saving surgery. The College of Physicians and Surgeons of Ontario (CPSO) has a test results management policy that states: “When a physician receives a clinically significant result for a test that he or she has ordered, the physician is expected to take appropriate action and follow-up with the patient with appropriate urgency.” In Matt’s case, the physician did not follow up according to the policy guideline, claiming, among other things, that he didn’t have Matt’s current phone number.
Three months after his PSA test, Matt called his physician’s office and asked the secretary what the results were. She told him the doctor only releases results in an appointment. Matt went that same day to his doctor. The PSA test, as unreliable as we know it can be, was so far off the charts that alarm bells should have been ringing in the doctor’s head as soon as he saw the numbers. A subsequent exam found a lump. A biopsy a week later confirmed the diagnosis and surgery was performed a month later. As a result of Matt’s diligence, not his doctor’s, we have been able to savour the celebration of the 60 years of our friendship.
If he had waited any longer for his physician to perform the duty stipulated in the College of Physicians and Surgeons of Ontario (CPSO) test results management policy, he might well be seriously or terminally ill instead of fully recovered.
The CPSO is currently reviewing its Test Results Management policy – and with good reason. Today (August 12) is last day for public feedback on the policy.
Test “mismanagement” is a contributor to patient harm, endangering patients such as Matt. What we don’t know is the extent of the harm caused. The policy is meant to “outline expectations for physicians regarding the management of all types of test results.”
The current ways doctors notify patients of test results are often inadequate. Patients may be told that the office either has a ‘no news is good news’ policy or they’ll be required to book an appointment in order for them to receive their test results. (Even if a patient doesn’t show up for a follow up appointment, however, the CPSO guidelines requires doctors to contact the patient if a result is concerning.) Since there is no OHIP billing code for test results consultations, it is impossible to track how many physicians use this follow up appointment practice.
While at times it is helpful to patient care to have a conversation about what test results mean (such as with PSA results, which can be complicated), it is a financial abuse of the system to call patients in simply to tell them “nothing is wrong.” (Doctors bill the government for these appointments.) It’s also abusive of patients and the costs they incur to come to an appointment – lost wages, travel costs, child care, unnecessary anxiety and emotional stress – all just to get an “all clear” declaration. In our view, this practice is disrespectful to patients.
The CPSO review of its policy includes asking for public submission. Patients who have suffered as a consequence of a physician’s ineffective test results management practice should be contributing to the discussion. Using Matt’s experience as a guideline, we have the following recommendations:
- The revised policy statement should indicate that it is an expectation that physicians reconfirm with the patient their current contact information and alternative/emergency contact information every time a test is ordered. They should also include that information on the original requisition and the copy. Potentially important information such as an upcoming vacation or change of address should also be included. The new policy should state that failure to notify a patient due to lack of current contact information is a breach of professional duty if the physician failed to request current contact information when completing the requisition for the specific test.
- The current policy, under the heading of “Appropriate Follow-up,” says that physicians are “expected to communicate results in a timely fashion, urgently if necessary.” Why is there only an expectation? The policy statement should change “expected” to “must” and state that failure to do so is a breach of professional duty. The vague reference to “timely fashion” should be replaced with a concrete timeline within which the duty must be performed. If Matt relied on his doctor to perform his duty, he could have become terminally ill as he would not have known of his illness until he was suffering symptoms many months later.
- Matt’s physician claimed he called the number for Matt that was in his records, but his records were incomplete. The current policy statement under “System Requirements” states that the system used by the physician must enable the physician to “record that a patient has been informed of clinically significant results.” The revised policy statement should state:
- That it is an expectation that the physician record the day the patient is informed of the test results. If there is an inability to contact the patient, the dates and means of the effort shall also be recorded by the physician.
- Physicians can’t relieve themselves of the duty to inform the patient of test results by expecting patients to make follow-up appointments for patients to receive the test results. The revised policy statement should state in the section of “Involving Patients” that follow up appointments should not be expected as a routine means for patients to be informed of negative results and that scheduled follow-up appointments do not diminish the duty of the physician to communicate the test results in a timely fashion to the patient. To commit to an authentic principle of “Involving Patients”, patients must be given equal access to their test results. Currently, some labs and some doctors offices will share test result information directly with patients through online platforms, while others won’t. In Nova Scotia, meanwhile all patients will be able to access their test results online. Patient access to their data is an underlying principle in shared decision making.
We are grateful that Matt woke up and said “what were those test results?” after waiting for over three months. This submission is for all those people who are not so fortunate.
Zal (right) and Matthew (left) are pictured above on a canoe trip with Matthew’s son.
The comments section is closed.
This is another example of creating bad policy because the poor practice of a few individuals. If I as a family doctor had to notify every pt of every normal result it would eat up enormous amounts of time making me unable to do other vital parts of my job. I could delegate it to my nurse but then she wouldn’t have time to do a lot of the other important things she does. Not only do I get the results of the tests I order but also the tidal wave of test results from patients of mine in hospital, ordered by specialists etc. Ever had trouble getting through to your family doctors receptionist? It would only get worse as office staff spend tons of time calling pts about normal results. Most people are difficult to get a hold of these days despite cell phones etc. It often takes multiple attempts to get someone on the phone. We could use email but then we would have to verify the email address every time we ordered a test as these change too. As for verifying phone numbers every time a test is ordered guess what, more time needed and less patient care being done. If I have a patient with a critical result even if we don’t have an up to date phone number we find them. We call a relative to get a number. We send a letter to the patient. We don’t give up. We document that we did these things. I don’t know if the doctor in question did these things or not. If he didn’t he should have. Having pts being able to access their own results can be somewhat helpful but it has limitations as well. The other thing we do is we call pts about test results we know they are going to worry about. Like biopsy results. We know pt is going to worry until they are told it is normal so we call as soon as we can that we got a normal result. Patients could do their part by informing the receptionist when they see the doctor when their phone number has changed etc.
There is one very simple solution to this very common dilemma….ensure it is the patient that gets the test results! By law, patients are entitled to all their test results and in a timely manner. Each time a patient has any test, the test results should automatically be faxed, emailed, or mailed to the patient at the same time they are sent to the patient’s physician to avoid this type of oversight. Any patient’s requests from any lab or hospital or any other medical related facility should provide the patient “their data.” This example is only one of many patient safety risks where there lack of proper communication in the health care system affects patients.
The CPSO have guidelines that may annoy some doctors and for patients, may confuse them into thinking that: as read, they “appear” comprehensive, therefore the doctor will follow the guidelines. Mistake, big time!. However, and this is the biggy…there is no enforcement of the guidelines and this is apparent in Matt’s case.
Elizabeth Rankin, BScN
ElizabethRankin.com
PS: I think the Canadian College of Physicians and Surgeons should set and enforce clinic practices concerning records management- among other quality of care issues. There should be an accreditation system for all outpatient physician clinics and there should be some manner of routine oversight, including patient experience/satisfaction measures.
I’m a social work practitioner myself, and now a chronic care patient, having worked in several health settings. My experience in BC, well it is appalling. It is hard to describe how rigid yet dissembled health services are in this province. I empathize with your situation and support the direction you suggest.
I sympathize and share your indignation about lazy, careless physicians with disorganized, poorly trained rreception staff. If you have ever seen ‘Little Britain’ you might remember Carol Beer, who featured once as a hospital information agent. You will have to look it up on You-Tube to understand the comparison between Carol and clinic office staff , at least here in BC.
When I secured a new GP after moving to Vancouver from another Health Region, he would not request my records from my previous physician or from other specialists. He said it was up to me to obtain and deliver my health records to his office. So I actually had to go photocopy my personal records, which I always request for myself now, and bring them to my GP’s office in person. This is of course, a cost cutting strategy, by transferring case management onto patients themselves.
Also, this new doctor did not send imaging or consult records to an ENT specialist when he made a follow up referral for thyroid issues. Another specialist office claimed they sent a consult report to my GP, but six months after the apt, my GP still did not have the report, and didn’t believe the test results when I told him the diagnosis. The GP office claimed to send a referral back to my neurosurgeon, but six months later the specialist had not received any information from this GP.
I’ve had two health conditions in BC that were not diagnosed until I went into crises when I was on vacation back east. One of these required a test for cancer, another required urgent surgery.
As a health professional myself, I would be fired if any of my patients complained of this experience. But physician clinics here seem to have lower standards and less accountability to patients than any other health profession, even to their College.
I agree that all patients should be getting test results as soon as the doctor does. I understand from my own experience that without a push our results, our information is sometimes left in a file, and not shared with the patient swiftly.
It is vitally important for our health and well being. Nothing less will do.
I do not agree with these guidelines. These guidelines above are a progress toward the right direction, but they are not enough. I think patients we should work toward making standard that patients will receive a copy of their test results, the same day their doctors receive it. The Lab test results would include explanation in plain language about how the test should be and how they should not be interpreted. To claim that patients cannot understand medical test results and therefore should not receive a copy of their lab tests results is insulting and is an excuse used to cover up a power imbalance. This is a paternalistic attitude that must go away. In my country of origin (a third world country), I would receive the test results before my doctors would. It is a shame that in Canada, a rich country, things are usually still far from this.
Related reading:
http://bmjopen.bmj.com/content/6/1/e010034.full
https://doctorsbag.net/2014/05/30/how-one-gp-gives-his-patients-access-to-their-electronic-health-records-interview/
http://www.the-hospitalist.org/article/sharing-notes-for-better-doctor-patient-communication/
Hello Alex: If you live in Ontario or BC you can access your results online through secure online access service called ‘my results’ in Ontario and ‘my ehealth’ in BC. These services are provided free of charge to citizens through LifeLabs and provide you with practical and timely information about results of tests you have completed through LifeLabs. Tens of thousands of Canadians are signing up for this service every week. For more information please check out http://www.lifelabs.com . I hope this helps.
Right on Alex…couldn’t agree more!