Case Studies

Test Tracking and Communication Failure

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On January 29th, a 50-year-old presented to her primary care provider (PCP) with complaints of mid and low back pain and associated muscle spasms. The patient was in remission from Ductal Carcinoma in Situ (DCIS), which was treated with a right-sided mastectomy three years earlier.

On March 12th, she called her PCP’s office asking for a referral to a physiatrist who had previously treated her. She also asked her PCP to order an MRI of her lower back due to continued pain. The PCP declined to order the MRI, deferring instead to the physiatrist as to whether one was indicated.

The PCP saw the patient a week later for continued mid and low back pain associated with muscle spasms coupled with a new complaint of strain in her rib cage and between her shoulder blades. Her PCP prescribed Relafen and referred her to occupational therapy in an effort to reduce her pain. On March 31st, the PCP received a report from the occupational therapist stating that the patient had unrelenting chronic lower back pain and varying left sciatic pain. The patient was scheduled to see the physiatrist on April 27th.

After examination, the physiatrist diagnosed lumbar segmental degenerative disease with axial pain, related to presumed instability in the facet, disc, and neurogenic components. He ordered a lumbar MRI and planned to meet with the patient to discuss her status after the MRI.

On April 29th the patient was seen for her annual breast cancer surveillance by a nurse practitioner (NP) at her oncologist's office. The NP noted that the patient continued to struggle with her chronic low back pain and was taking Relafen daily. A copy of the office note was sent to the PCP.

The patient underwent an MRI on April 29th. The images showed a “marked change in the bone marrow signal pattern since the study three years prior, with increased and decreased T1 and T2 signal areas.” While unable to identify a focal destructive process, the radiologist concluded the current findings were highly worrisome for diffuse metastatic disease. He recommended a nuclear bone scan and bone marrow aspiration. Copies of the report were sent to the patient’s PCP, physiatrist, and breast surgeon, but not to her oncologist.

The PCP received his copy of the MRI report on May 4th. He made a note to himself to contact the patient’s oncologist, but he did not contact the oncologist or inform the patient about the report.

On June 15th, the physiatrist reviewed the MRI report for the first time during his appointment with the patient. He told the patient that there were metabolic abnormalities on her MRI. The physiatrist called the PCP on June 16th to discuss the findings, and they both agreed to get her oncologist involved. The PCP noted in his office note that he felt it was appropriate to have the oncologist review the MRI and decide about the need for further diagnostic studies prior to alarming the patient about the possible diagnosis. Following the conversation, the PCP ordered a bone density study, which he testified was on the advice of the physiatrist. The PCP noted in his records that he questioned if the patient needed a bone marrow biopsy or bone scan.

In late July, her PCP spoke to her oncologist regarding the MRI report and had a later conversation about the oncologist’s interpretation of the report. The PCP testified at his deposition that during this conversation with the oncologist, the oncologist told him they had reviewed the MRI and that no further testing was needed because DCIS does not metastasize. However, the oncologist testified that they asked the PCP to send them the images and to send the patient to the office so that they could evaluate her. The oncologist denied stating that DCIS would not metastasize and denied that they ever reviewed the MRI or report.

Following the conversation with the PCP, the oncologist did not contact the patient but relied on the PCP to arrange for the patient’s appointment at the cancer center. The PCP delegated a staff person to inform the patient that her MRI had been reviewed by the oncologist and that no further testing was needed.

The patient returned to the PCP office for two more visits on August 12th and August 13th complaining on each visit of mid and low back pain. She saw two different physicians on these visits. One physician did not review the MRI report of April 29th and the other physician did review the report but did not inform the patient of the findings or initiate a work-up or referral.

On August 18th the patient saw her physiatrist for continued pain complaints. He ordered a thoracic and lumbar MRI.

The patient presented to the emergency department on August 19th, complaining of extreme pain in her thoracic and lumbar spine. She was diagnosed with hypercalcemia attributed to diffuse metastatic cancer in her thoracic, lumbar, and sacral spine. Her calcium levels were normalized soon after her admission, and she was discharged from the hospital on September 18th after undergoing treatment for her metastatic cancer. She continued to receive palliative radiation treatment, hormonal therapy, and chemotherapy on an outpatient basis until her death two years later.

The patient brought forward a claim alleging that the defendants were negligent for failing to refer her in a timely fashion for diagnostic testing when the MRI suggested metastatic disease. As a result of the delay, she suffered unnecessary and excruciating pain and endured a lengthy hospitalization. After her death, the patient’s sister substituted for the plaintiff.

The case was ultimately settled with the settlement amount being split between all three defendant physicians.

Although her PCP, physiatrist, and oncologist were all aware of the findings of her MRI, none of them informed the patient of the findings or formulated a treatment plan.  The physiatrist ordered the MRI but did not take responsibility for informing the patient. While all three providers discussed the findings, they never agreed on who should inform the patient. As a result, she suffered intense pain for several months before presenting to the emergency department. Each seemed to expect another care team member to inform the patient and develop a treatment plan.

The PCP’s office did not appear to have an established referral process. There was not a clear expectation of how care would be continued after the patient was referred to the physiatrist. The covering physicians in the primary care office either did not review the MRI results or did not initiate a treatment plan, even when the patient came to the office complaining of continued back pain.

Instead of bringing the patient in to discuss the finding or ensuring that the oncologist would review the finding with the patient, the PCP instead delegated this step to a staff person who provided incorrect information.

It is hard to know the reasons each provider was so reluctant to share the findings with the patient, but the results were months of untreated pain and possible worsening of the disease process.

This case happened before the widespread use of patient portals; however, it is conceivable to envision a situation where the patient viewed the report on the portal, but each provider avoided the conversation with the patient.

1. Notification of Test Results:
   1. Ensure that patients are informed of both normal and abnormal test results. Utilize patient portals to make these results readily accessible to patients.
2. Patient Portal Access:
   1. Assist patients in setting up and accessing the patient portal to ensure they can view their test results and other important health information.
3. Results Management Policy:
   1. Develop a comprehensive written policy for managing test results. This policy should outline the steps and expectations for the entire results management process.
4. Referral Expectations:
   1. Clearly communicate the expectations of referrals to both the patient and the consulting physician. For example:
      1. Consultation Only: If the referral is for consultation only, the consultant should forward their assessment and recommendations to the referring physician for further evaluation and consideration.
         
      2. Transfer of Care: If the referral involves a transfer of care for a specific condition, the consultant should assess the patient and implement the recommended treatment plan.