Wish You Were Here

One of the most important communications that an office-based physician makes is the one to get his or her patient to return for follow-up testing. While physicians are hesitant to unduly worry a patient over an early questionable finding, they must find the right words and means to convey the importance of the follow-up test.

A 32-year information technology manager presented to Dr. P, a primary care physician, with episodes of bloody wipes over 2-3 months and a family history of colon cancer, including the death of his maternal grandfather. The patient denied any change in bowel movements in the six months preceding the medical visit.

Dr. P noted normal bowel sounds, non-tender abdomen, and no nausea. Dr. P ordered a Chem 20, complete blood work-up, urinalysis, hemoccult x 3, and a lipid profile. Dr. P wrote to the patient regarding lab results showing somewhat high cholesterol, a positive hemoccult, and a low hematocrit.

In an office visit two weeks later, Dr. P discussed the test results with the patient. In response to the positive hemoccult test, Dr. P performed a rectal exam for hemorrhoids with an anoscope. Dr. P found no obvious site of bleeding with no tags, hemorrhoids, or fissures. Dr. P mentioned to the patient that there was blood on the anoscope.

In taking a further history, the patient related that the bloody wipes usually followed constipation or hard bowel movements. Dr. P recommended to the patient that he increase his dietary fiber and take Metamucil. Dr. P then recommended that the patient return in one month for a gastroenterological exam.

That recommendation, however, was subject to interpretation. The patient recalled from the visit that Dr. P wanted him back only if the bleeding continued. Dr. P, however, said that his note indicated that he wanted the patient to return in 30 days regardless. A “superbill” indicated that the patient was to return in one month if bleeding continued. Finally, the chart contained Dr. P’s handwritten Post-It note requesting the front office to “please make sure the patient has a follow-up in the next 30 days.” By all indications, the office did not take any steps to schedule a return appointment.

After taking the Metamucil, the patient noticed no bleeding, and did not return to Dr. P. Some nine months later, the patient noticed bloody stool, which was again relieved with the Metamucil. Two months later, the patient saw a new primary care medical group – a change brought about because of a new job -- with complaints of flu-like symptoms and the history of bloody stools. The physician seeing the patient that day recommended that he return for a sigmoidoscopy. That exam, taken one year and a day following the patient’s last visit to Dr. P, found a minimal friable mass and moderate internal hemorrhoids. A colonoscopy and biopsy revealed an invasive moderately differentiated colonic adenocarcinoma, grade II/IV. A CT scan described multiple lesions on the liver indicating metastasis.

In the medical malpractice suit brought by the patient and his wife, the consulting experts were critical of the medical office’s failure to schedule the follow-up visit requested by Dr. P. There was less consensus on whether Dr. P should have done more even before asking the patient to return in 30 days. Eventually, the medical group resolved the lawsuit through a settlement.

High-risk patients who have significant, yet unexplained symptoms will need a staff’s priority for scheduling recalls. Some offices schedule future appointments for all patients and many others use a tickler system to initiate action if a patient does not return or if a lab result does not arrive.

When such effective systems are in place, the physician then must choose (and document) the right words to motivate the patient to action.


Gordon Ownby is CAP-MPT’s general counsel. Comments on Case of the Month may be directed to gownby@cap-mpt.com.