Positive tests - surprisingly, patients are not always as receptive as you'd expect them to be

Swerlick, Robert A rswerli at EMORY.EDU
Tue Mar 10 16:44:10 UTC 2015


I agree that Dr. Bruno’s description highlights the complexity of information exchange. What I would also highlight is that more conventional venues for information exchange (patient office visits) suffer from the same problems. We simply were not aware of the issues to the same degree and/or we use a different set of descriptors to catalogue the issues.

Patients come to a venue to address a problem they are concerned about. We deploy tools which detect a variety of signals, independent of the reason the patient originally sought care for. We are surprised when the patient has no interest for pursuing problems which they do not perceive.  Perhaps we should not be so surprised they do not want to buy or product or service that we are selling them when they see little or no value in them.

Rob, I agree that  the new communication tools have not been evaluated adequately. Neither have the old tools.

Bob Swerlick

From: Robert Bell [mailto:0000000296e45ec4-dmarc-request at LIST.IMPROVEDIAGNOSIS.ORG]
Sent: Tuesday, March 10, 2015 11:55 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Positive tests - surprisingly, patients are not always as receptive as you'd expect them to be

Wow, what a great reply.

Beautifully expresses all the complexity of medicine and the challenges to reduce error against a relentless sea of obstacles that helps create error.

Speaks to patient communication and Portals being adequately evaluate prior to introduction.

Well done Michael Bruno.

Rob B

Sent from my iPad

On Mar 10, 2015, at 6:38 AM, "Bruno, Michael" <mbruno at HMC.PSU.EDU<mailto:mbruno at HMC.PSU.EDU>> wrote:
Thanks, Tim,

It’s great to hear from a fellow “Quality Officer” in a medical practice.  I’m also a quality officer, for a large academic department of Radiology.  This particular issue, of communicating effectively with our patients, is near & dear to my heart.  I’d like to briefly share our own experience in alerting a subset of patients to their test results, an experience which surprised me and my team here and may surprise others on this listerv as well.  We were surprised to encounter a population of patients who were remarkably disengaged, and who weren’t particularly receptive to hearing from us with their test results.  This was quite the opposite of what we expected.

In the practice of modern radiology, we encounter a good many unexpected findings—items of varying importance that are turned up on imaging tests that need to be followed up (often after a suitable delay to allow us to better characterize them).  While such findings need to eventually be addressed clinically, they are not the immediate reason for the patient coming to the doctor or undergoing their imaging test.  We dutifully report all of these “incidental” findings to the ordering physician—phoning them when the surprise is a critical one—and trusting them to read our written report when it is not.  As a corollary, there’s quite a bit of pressure to make our reports timely and clear, and these days our formal, signed final reports are predominately delivered electronically through the EMR in a matter of minutes, although providers outside of our center may still get their radiology reports via fax or even through the regular mail.  The issue is particularly problematic for us in Radiology where Radiology intersects the Emergency Department.  We invest a lot of resources to the E.D., and most of our final, written reports on E.D. patients are delivered literally within minutes, plus we always have someone (a faculty member, resident trainee, or both) physically stationed in the E.D. itself to provide immediate availability for consultation.

That’s all well and good for the acute findings, i.e., those addressing the clinical question that brought the patient into the E.D., but it tends not to work all that well for those incidental findings unrelated to the immediate problem and that require a medium to long-term follow up—follow-up which is outside of the purview of the E.D.  In such cases, it falls to the patient’s primary care physician (if there is one) to follow up on the incidental findings, and it’s almost useless for us to even alert the E.D. physician to those findings.  In many cases when we report the findings to the ED physician the patient still isn’t even told of them by that E.D. physician.  Rather, patients are directed to sign a form at the time of their discharge from the E.D. in which they promise to “follow-up with PCP.”  This promise to follow up is generally little more than a charade.  From the patient’s standpoint, they often feel that they’ve (1) just SEEN a doctor, and (2) been SCANNED from top to bottom, and therefore they should be “all good.”  At least until their next acute problem arises and they return once more to the E.D.  In a handful of cases, depending on the nature of those incidental findings, that is a very dangerous complacency.  Their PCP, if they even have one, may never learn they were even seen in the E.D., much less that there were CT or x-ray findings from that E.D. visit which will need to be worked up or at least followed.  So you see the problem.

To address this, we’ve developed a “failsafe” plan to alert the patients directly to their incidental findings requiring follow-up, and to encourage them to obtain the recommended follow-up with their PCP.  We also direct them to our Dept. of Family & Community Medicine in the event they don’t have a PCP (which is unfortunately a fairly frequent situation in the E.D. population).  We do so by mailing them a letter.  This is an unusual type of direct communication for Radiologists.  In the U.S., we Radiologists have traditionally been the “doctor’s doctor,” communicating our findings and opinions only with the referring physician, who then relays our impressions to the patient (who, in turn, generally assumes that it was their own doctor who interpreted their CT scans and generated the diagnostic opinions).  The idea for our “Failsafe” program came from the Joint Commission NPSG about involving patients in their own care as a specific safety strategy—and it puts the patient in the middle of the communication chain between us and their PCP.  When we proposed the idea of having Radiologists send letters directly to patients – letters addressed to specific patients and signed by a specific Radiologist(!) – with the purpose alerting patients to abnormal findings on their scans without any intermediary physician there to explain the findings, it raised a lot of eyebrows, not least among the Radiologists themselves.  Many worried that the clinical physicians would not appreciate our getting between them and their patients, and others were worried that patients would call us incessantly with questions and consume too much time, destroying our RVU-based productivity.  We also worried that receiving a Failsafe letter would be unduly frightening for patients.  But none of these concerns turned out to actually be a problem.  Our faculty physicians were very receptive to Failsafe, and they universally appreciated the added measure of safety for their patients that the new program provided.  If anything, they wanted to see the program expanded.  And very few calls from patients came to us.

Our Failsafe letter does not attempt to explain the findings or their significance to the patients.  Rather, it merely alerts them that “their Radiologist” found something on their scan requiring follow-up, and urges them to see their doctor to discuss the findings (or call the Family Medicine office to arrange a follow up if they don’t have their own PCP).  We have so far limited the program to E.D. patients, based on the rationale above, and currently we send out about 6 – 8 letters per week, and have been doing so for about three years now.   But when I phoned bunches of these patients to see what their reaction to the letter had been, and to ascertain whether it had achieved its intended purpose, I discovered that patients were fairly uniformly disregarding the letters.  Most never even returned my calls.  Those who did seemed completely unconcerned and none even asked me what the findings we were pursuing were!  They simply did not care to know—they were feeling well, and they were not receptive to any potentially worrying information.  Far from being frightened by the letters, they were not even concerned when the letter was followed up by some doctor (me) phoning them repeatedly, leaving multiple voicemails and messages with their family members at home and co-workers at their places of employment.  It was clear that these patients could not care less about our findings, our letter, or whatever it was I may have had to say to them on the phone.  In short, we encountered a large group of patients who were so unconcerned and unfrightened about their test results that nothing we tried could frighten or concern them!

This situation was essentially 180 degrees diametrically the opposite of what we had expected—which was that patients would be highly invested in the results of their studies, that they would be anxious to learn what their imaging showed, and would be pressing their physicians for answers.  We expected the phones to be ringing constantly once the first batch of letters went out.  What we found instead was that, at least for the population seeking their medical care in the E.D., with a few notable exceptions, our patients were pretty much un-engaged with their own care beyond the acute episode of care.

We have been struggling with this patient engagement issue and are now working toward developing more effective ways to augment our program and try to reach these patients.  But I would suggest, based on our experience, that merely sending patients the results of their lab tests by mail is simply NOT going to be adequate across the board.  Some patients are turning out to be very hard to reach.

All the best,

<image002.png>
Michael A. Bruno, M.D., F.A.C.R.
Professor of Radiology & Medicine
Director of Quality Services & Patient Safety
The Milton S. Hershey Medical Center
Penn State College of Medicine
500 University Drive, Mail Code H-066
Hershey, PA  17033

Phone: (717) 531-8703
Fax:      (717) 531-5596

e-mail: mbruno at hmc.psu.edu<mailto:mbruno at hmc.psu.edu>


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From: Timothy Stevenson [mailto:Timothy.Stevenson at SSWAHS.NSW.GOV.AU]
Sent: Monday, March 09, 2015 4:50 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] FW: [IMPROVEDX] Positive tests

It is interesting, and yet a little disconcerting, to see the variation in perception as to how important and/or necessary it is to provide the patient with results from tests ordered that are “good news”. From the patient’s perspective, “no news” does not necessarily mean “good news”. Rather, it means “What did the tests show?” anxiety. Remember that the patient came to see you because “something was wrong”. The fact that the test comes back with a “There is nothing wrong” result does not answer the question the patient originally came with. As a Quality Assurance officer I regularly talk to patients who either have not heard the results of any tests they were sent for, have not had the results of the tests clearly explained to them or have been told “the tests show nothing is wrong”. Their original question of “what is wrong with me” or “what is causing me to feel like this” remains unanswered.
Perhaps we need to go back to the original discussion with the patient where informed consent was obtained to undertake/ refer for the test. Receiving the results with an explanation as to what they show or don’t show must be a part of the overall process. I would disagree that simply sending the results to the patient in the mails is adequate. I have been handed copies of my blood test results with “These show everything is alright”, only to see **hi** and **lo** next to some results. If the LAB flags these areas, then these results are “not okay”.
I appreciate that explaining all results will put extra strain on the already busy medical practitioners, but perhaps testing will become more targeted.

Tim
Timothy Stevenson

Quality & Safety Manager | SWSLHD Community Health
Executive Unit, 1 Bolger Street, Campbelltown, NSW 2560
Tel (02) 4621 8767 | Fax (02) 4621 8775 | Mob 0455 075 055 | timothy.stevenson at sswahs.nsw.gov.au<mailto:timothy.stevenson at sswahs.nsw.gov.au>
http://www.swslhd.nsw.gov.au/CommunityHealth/

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From: Maureen Cahill [mailto:MCahill at NCSBN.ORG]
Sent: Tuesday, 10 March 2015 6:48 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Positive tests

Would it be possible to negotiate with a practice’s  laboratory provider that at a minimum all results are mailed and then abnormal results could have an additional faster track notification?
Maureen

Maureen Cahill [Associate] 312.525.3646 (D) mcahill at ncsbn.org<mailto:mcahill at ncsbn.org>
National Council of State Boards of Nursing (NCSBN) 111 E. Wacker Drive, Ste 2900, Chicago, IL 60601-4277 312.279.1032 (F) www.ncsbn.org<http://www.ncsbn.org>
Our Mission – NCSBN, Leading in nursing regulation

From: Avrum H. Golub, M.D., J.D. [mailto:avrum_h_golub_md_jd at ME.COM]
Sent: Monday, March 9, 2015 11:14 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Positive tests

Lest we forget, patients are people and physicians may be patients.

Please consider the “Golden Rule” and good manners.

And, of course, the reassurance to a patient that we can convey.

If not the physician, perhaps the ministering angel of the bedside (nurse) or another physician extender who has empathy and compassion.

Some of the incomprehensible telephone reports (or not report) that I, as a patient, have received from physicians’ staffs are rude and anxiety provoking, at least.

I am a Pathologist.
Avrum H. Golub, M.D., J.D.
On Mar 8, 2015, at 8:10 PM, Pauker, Stephen <SPauker at TUFTSMEDICALCENTER.ORG<mailto:SPauker at TUFTSMEDICALCENTER.ORG>> wrote:

In my experience and writings , negative or normal test results can be quite important in making a diagnosis, so not communicating them to the patient can be withholding key information. All results positive or negative should be communicated. Further withholding them can sometimes lead to repeating the test

Steve



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-----Original Message-----
From: Robert Bell [rmsbell at ESEDONA.NET<mailto:rmsbell at ESEDONA.NET>]
Sent: Sunday, March 08, 2015 01:33 PM Eastern Standard Time
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: [IMPROVEDX] Positive tests
Many doctor's offices only call or mention to patients positive test results that have been undertaken (particularly lab tests). Is that a good thing and does it in any way impact diagnosis?

Also, what are the effects of the new electronic portals on diagnosis. It is a big change in medicine.

Rob Bell

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