There Are No Shortcuts for Test Results

In the business world, reports addressed to high-level managers frequently contain an “executive summary.” Even peer-reviewed articles published by physicians often begin with a condensation of the article’s findings.

Unfortunately, physicians reviewing lab reports get no such special treatment: They still must go over each finding, line-by-line, page-by-page. Once a physician orders a test, it is important for him or her to review all of it – and to look at those values that may not have been of initial concern.

A 25-year patient went to the emergency room because of right lower quadrant pain for two days. The ER physician believed the gentleman had appendicitis and referred him to Dr. GS, a surgeon, for evaluation. Dr. GS reviewed the lab tests ordered by the ER doctor and formed the impression of gangrenous appendicitis. Dr. GS admitted the patient and assisted Dr. LS -- the lead surgeon and Dr. GS’s employer -- in a mini laparotomy that turned into an open appendectomy to remove a perforated appendix. The patient arrived in post-op in good condition and was discharged several days later with instructions to follow up with Dr. LS in one week.

In his preoperative request, Dr. LS had checked off the need for labs, CBC, and a urinalysis. Two days after surgery, Dr. GS ordered a WBC and chemistry panel because of his concern over the patient’s slow return of gastrointestinal function. Dr. GS’s reason for ordering the test was to check on the patient’s white blood count and electrolytes. By the next day, the patient had good gastrointestinal function.

The full lab results were formally issued the day after discharge and were initialed by Dr. GS. Dr. LS did not review any lab reports.

What Dr. GS did not notice was a 3+ protein on urinalysis and abnormal BUN and creatinine levels. These reports were not in the patient’s office chart for his post-op visit with Dr. LS six days after discharge, but at some point made it to the file.

The patient did well for the next 34 months, but eventually went to an internist because of difficulty breathing. The patient’s white blood count was elevated and a chest x-ray revealed bilateral infiltrates. The internist admitted the patient to the hospital, where further treatment revealed hypertension, myocarditis, congestive heart failure and renal failure. After a transfer to another hospital, the patient was diagnosed with malignant nephrosclerosis and chronic renal disease.

The patient subsequently sued Drs. GS and LS for their alleged failure to timely diagnose his renal disease and failure to refer. On expert review, there was some question on whether an earlier diagnosis of the patient’s renal disease would have made much of a difference in the patient’s long-term outcome. Notwithstanding that avenue for the defense, there was little to explain the failure to thoroughly review the tests ordered. The claim was resolved informally prior to a jury trial.

Patients rightfully expect that if a physician orders a test, he or she must have a valid reason for doing so. If a physician then fails to review all the results of the tests, patients – and juries – will likely not accept any kind of explanation for that omission.

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