Phoning results to clinicians and resulting madness.

[LADoc00]

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I do alot of medical legal stuff and am seeing more and more administrative suits that literally boggle my mind.

I cant even get my head around some of the logic being used but attorneys are getting this nonsense SOMEWHERE which means other pathologists out there are foolishly spreading false statements that the "standard of care is X" when they have no idea what they are talking about from the a compliance or legal stand point and dont realize that very statement could lead to incredible problems down the road.

Q: When are you required to call a clinician with a result as a "critical value" from a surgical pathology report?
A: When calling a clinician with a specific result is PART OF A SIGNED AND IMPLEMENTED STANDARD PROCEDURE to do so. To have a specific critical value, most states require labs review this list AND seek approval from the medical staff leadership in writing. Which means you dont just do whatever you want and call that "standard of care" or "compliance." It has to be both the community standard AND compliant within the law.

I would advise people that have procedures they claim to do like "call all new cancer diagnoses" which I HIGHLY advise you dont do, to memorialize these procedures properly and note the completion of the within the body of the report EVERY SINGLE TIME.

I would advise people stick to calling all frozen section results, tracking TAT and noting the precise language of the relayed communication on your end within the body of the report. The exact words used, such as "I favor carcinoma on representative sectioning of this is specimen, but defer final diagnosis to permanent sections. Tissue obtained is adequate for diagnosis."

If you are phoning OTHER results as part of a standardized procedure to do so, realize you have to:
1.) indicate time called, not merely the date
2.) indicate the precise words used in the communication and call duration
3.) preferably have an additional witness adjacent to you to corroborate the call
4.) clearly input the above data into the body of the final pathology report

Clinicians have begun a well thought out campaign to blame their lawsuits on pathologists with the aid of evil and clever attorneys so be aware.

AND if you have an outpatient provider who is incredibly incompetent, disorganized or otherwise a menace, I would HIGHLY advise you cut ties with them and ask them to send their work to Quest. Trust me on this. Trust me.

 

[McSorely]

We had a case where a patient called the state health board to file a complaint. He left the hospital and claimed a few months later that he was never told he had late stage cancer. The pathologist had given a prelim to the hospitalist that the patient had adenocarcinoma, but was waiting for stains to finalize the report. The report was finalized after the patient had already been discharged. The hospitalist had documented all over his notes that he spoke to pathology and explained the diagnosis to the patient clearing the pathologist. However, before finding this in the notes the investigators wanted an explanation regarding why the pathologist had not documented speaking to the hospitalist in the finalized report. Ultimately the investigators were satisfied with the hospitalist’s notes and dismissed the complaint.

 

[LADoc00]

I think the law will turn on this and that eventually there will be precedent that requires the PATIENT to get their own results. This movement of burden would match other professional fields and also dovetail nicely into a patient-centric focus mission statement: Hey, here is your access password, go online and get your results and follow up on your own.

 

[dingdong28]

I don't have much to contribute to this thread but all I want to say is: I've always had a tremendous amount of respect for every pathologist I've worked for, but my respect for all pathologists just soared to even larger measures today. I'm an MLT and had no idea you all had to deal with the same issues like TATs, calling critical/providing in-depth documentation of calling results, as well as many others. It's almost like we deal with the same issues, except ours are with the nursing/other allied staff and at times are extremely frustrating, cause delays in treatment and blame the lab because the non-lab staff mislabeled specimen (and we are unseen by everybody). While we have similar issues, yours are with others physicians, providers, administrators, and lawyers and certainly hold more consequences or there will be lawsuits against you when someone claims you didn't document something.

So, I just want to say thank you and apologize since I didn't have much to contribute to this thread from the POV of a pathologist.

 

[yaah]

Always document. We had a lawsuit averted in our group long ago (before I joined) where a clinician was claiming he was never informed about a critical finding on a liver biopsy or something (that needed urgent attention). Case had been shown around the department by the signing pathologist, but a different pathologist had called the clinician, and wrote on our dated consult sheet that he told Dr X at X;XX PM that the biopsy showed the important finding.

But yes, whatever you do, please follow your procedure. It is catnip for lawyers (and CAP inspectors, by the way) if you have a procedure and don't follow it. Even worse in many cases than not having a procedure.

 

[Torsed]

I call and document all malignant diagnoses other than rando skin CAs. Clinicians are too busy and there was a bad lawsuit up the road where this wasn’t done and myeloma missed for many months. Pathologist argument on that was the report was faxed, didn’t hold up. We all know office staff toss everything to include reports.

As far as a procedure list in anatomic there are articles on this but I use my gut: clinician A is a ding a ling, a try to help them out if something bad.

I totally agree with much of LADocs views. Someone is coaching the attorneys. I’ve got enough hate at big labs to consider this but haven’t gone to the dark side yet.

 

[Alteran]

I call and document all malignant diagnoses other than rando skin CAs. Clinicians are too busy and there was a bad lawsuit up the road where this wasn’t done and myeloma missed for many months. Pathologist argument on that was the report was faxed, didn’t hold up. We all know office staff toss everything to include reports.

As far as a procedure list in anatomic there are articles on this but I use my gut: clinician A is a ding a ling, a try to help them out if something bad.

I totally agree with much of LADocs views. Someone is coaching the attorneys. I’ve got enough hate at big labs to consider this but haven’t gone to the dark side yet.

If I were the defending attorney, I would have asked the ordering provider or at least posited to the clinician:

1. Is it routine practice for you to order studies and not follow up with the result(s) of said studies?
2. Do you have procedures in place in your office to manage and review results for tests that you order under your medical license?
3. Do you take professional responsibility for the patients under your care and all results pertaining to them?

I think that would have ended it there. I don't buy the "we're too busy to keep track of all this stuff" argument. If you order it, you're responsible for it. Period. If there was proof that the report was faxed and received in a timely manner and there was no error in the diagnosis, any competent lawyer should have been able to toss the responsibility of the result onto the provider.

As for procedures, CAP has an AP checklist item regarding this almost forcing you to have a policy regarding it. We wrote it as only calling when its an "unexpected" finding (i.e. malignancy was not on the clinical differential). If the clinical features are that of malignancy or it comes down labeled as a "mass", and we have tumor, we don't routinely call.

 

[dingdong28]

I'm going to bump this thread because our lab has been having issues with this and I'd like to know what your lab/histo techs and you do. As a lab tech, I had to call a critical BUN on an outpatient for Dr. Cardiologist. Dr. Cardiologist's office phone number is located at the main campus (no answer, voicemail full). I call a patient scheduling number (tried this 3 times) and ask if they have any other contact info: Got forwarded back to office phone number. I tried using this fancy new paging system (DocHalo): Dr. Cardiologist isn't in the system. Pushed this over to our [interim] manager before going to our medical director (following my chain of command) who told me to go to straight to our medical director. Our medical director called the patient and left them a voicemail to call the cardiologist in the morning regarding a critical lab result, who would hopefully call the lab about said critical lab result. Dr. Cardiologist finally got their result after another one of our staff called after 9 am, nearly 19 hours later.

This exact scenario happened to another lab tech calling a critical result and a histo tech who had to call a critical carcinoma biopsy result, but each couldn't get into contact with the ordering physician and had to get our medical director. Why order testing when we have no way of being able to contact you if we find some critical results? I don't understand how that makes any sense.

How do you/your lab staff handle these scenarios?

 

[yaah]

When you get issues like this, if you have a receptive medical staff and administration (can be a big if), you escalate to department chairs. There are some who would call the head of cardiology when they don't get the on call person. Others will call the patient and send them to the ER - it teaches some clinicians to return their pages. Unfortunately this doesn't always work - there will always be doctors who refuse to take calls from the lab after hours. It may become a choice between their business and their preference - if that becomes the case you can bring in whoever owns the lab (hospital, whatever) and make them deal with it.

If your medical staff policy has teeth, you can also make it a condition of hospital staff membership to be available (or have someone on call for you) for calls such as this.

 

[deleted314957]

When you get issues like this, if you have a receptive medical staff and administration (can be a big if), you escalate to department chairs. There are some who would call the head of cardiology when they don't get the on call person. Others will call the patient and send them to the ER - it teaches some clinicians to return their pages. Unfortunately this doesn't always work - there will always be doctors who refuse to take calls from the lab after hours. It may become a choice between their business and their preference - if that becomes the case you can bring in whoever owns the lab (hospital, whatever) and make them deal with it.

If your medical staff policy has teeth, you can also make it a condition of hospital staff membership to be available (or have someone on call for you) for calls such as this.

We had a “professional practices improvement committee” where we would call “those types” on the carpet and we really used some teeth if there was any recalcitrance after the first heart-to-heart discussion with the offender. We did not tolerate that crap or verbally abusive “god” complex doctors. We actually drove more than a few away to our delight.

 

[yaah]

Yeah, that sounds like an effective system - we have department heads here who want to know when certian docs aren't returning their pages, because they want to address it and not leave it to us. I actually had a family med chair tell me if a doc wasn't returning their pages to call her instead. That's rare! But it really does require buy-in from lots of areas otherwise the lab is forced to deal with problems repeatedly, as no one else will take responsibility.

 

[pathology1234]

I have a related question. As a current fellow, we are required to phone all new malignancy results to clinicians. Not just unexpected malignancies, but also cases that were highly suspicious for malignancy clinically and even known malignancies that were not previously seen in house. Many clinicians are hard to reach and it is not uncommon for us to spend an hour (or more) daily trying to reach different clinicians.

Is this common at all in the real world? As I cannot imagine a pathologist wasting an hour of their time everyday doing that.

 

[Med Director New England]

I have a related question. As a current fellow, we are required to phone all new malignancy results to clinicians. Not just unexpected malignancies, but also cases that were highly suspicious for malignancy clinically and even known malignancies that were not previously seen in house. Many clinicians are hard to reach and it is not uncommon for us to spend an hour (or more) daily trying to reach different clinicians.

Is this common at all in the real world? As I cannot imagine a pathologist wasting an hour of their time everyday doing that.

No
You’re correct no one in the real world do this. Also most groups delegate this task to a secretary / call center or have an informatic solution built into the EMR to insure the provider gets the result.

Your dept should re-examine this policy.

 

[deleted314957]

I have a related question. As a current fellow, we are required to phone all new malignancy results to clinicians. Not just unexpected malignancies, but also cases that were highly suspicious for malignancy clinically and even known malignancies that were not previously seen in house. Many clinicians are hard to reach and it is not uncommon for us to spend an hour (or more) daily trying to reach different clinicians.

Is this common at all in the real world? As I cannot imagine a pathologist wasting an hour of their time everyday doing that.

You pick up the phone and tell the lab secretary (or similar), “ please get Dr. Jones on the phone for me regarding the biopsy on Mrs. Smith”. When they have raised Dr. Jones, they transfer the call to you. I do not see the problem.
There is a BIG problem if a physician has to bird dog this situation all day.
If house staff cannot do this at your particular institution then you are in a s****y program.

 

[yaah]

Many centers are moving towards new methods of communication (think secure texting) which makes communicating critical results easier, because you can get a read receipt and such. That is probably the future.

But in general I agree, all new malignancies do not need to be phoned. Unexpected ones do (like nasal sinus contents that have a surprise melanoma), but typically they are doing biopsies because they think there might be cancer there. It's OK to have all new malignancies faxed or something, but expecting direct communication of ALL new malignancies is a bit of a red flag in regards to how communication actually works at your institution.

 

[cmz]

Isn't this part of MIPS now?

 

[ScubaV]

This is where a unified EMR is nice. If it's not an urgent or complex situation that requires real time conversation, I can fire off an Epic message directly to the clinician and document that fact in my report.

 

[deleted314957]

Have NO f*****g idea what an Epic message is. Ties in well with what I finally gave into today.
Tough to let that little piece of paper go. Officially retired my medical license. (even if i hadn’t used it for 6 years)

 

[ScubaV]

Have NO f*****g idea what an Epic message is. Ties in well with what I finally gave into today.
Tough to let that little piece of paper go. Officially retired my medical license. (even if i hadn’t used it for 6 years)

Epic is a widely used EMR (electronic medical record). There's a function within it to essentially send an in-application email to any registered user. Unlike regular email or fax, there's not really a question of did they check it because in order to do clinical work you have to use Epic and thus be exposed to messages.