Missing a diagnosis is, obviously, something both doctors and patients continually want to avoid.
But when it happens, is it completely the doctor’s fault? That’s a question Pauline Chen addresses in a recent column. When it pertains to primary care, it all comes down to followup. She cites a recent study looking at breast cancer diagnoses and found that, “roughly a quarter of patients had experienced process of care lapses,” and, both “doctors and patients contributed equally to the resulting diagnostic failures.”
I previously wrote that follow-up is a huge problem, with a study showing that 7 percent of abnormal test results were never communicated to the patient. Physician practices need to do better in that respect.
But should patients who intentionally don’t followup, or shun medical advice for ineffectual alternative therapies, be completely blame free?
Internist Saul N. Weingart puts it nicely, saying that, although the responsibility shouldn’t be shared 50-50, “I also don’t think it’s 100-zero. I think there’s a shared responsibility. But given that the patients who fall through the cracks are usually the least resourceful and most vulnerable, there is at least a moral obligation for clinicians and health care systems to provide a robust safety net for these patients.”
Related posts:
- Does it matter how doctors give patients their diagnosis?
- When patients won’t take personal responsibility
- Are patients refusing doctors who no longer do hospital work?
- Personal responsibility: Penalties non-compliant patients
- Why hospitalized Medicare patients get re-admitted so frequently
- Should patients lie to their doctors?
- Are patients who enter hospice care really abandoned by their primary care doctors?
{ 12 comments }
From a legal standpoint, the apportionment of fault is left up to a jury to figure out. If the evidence shows that patient had responsibility to follow-up and didn’t, then the jury would attribute a percentage of liability to the patient. If the evidence shows that the physician did not follow the established standard of care for managing that patient, then the jury would attribute a percentage of fault to the physician. I work on a number of cases wherein the result falls squarely within these two questions for the jury. Most resolve with the jury considering what a reasonable patient would have done to be proactive in their own care and to what degree, if any, the doctor breached the community standard.
From a non-legal sense, the management of a patient’s care varies amongst the specialties. A primary care physician, as a guardian and gatekeeper to a patient’s care, may be charged with being proactive in following up on a patient who fails to follow instructions and advice. Ultimately, that is a matter that the standard of care for that specialty to establish. However, how about physicians who do not have established relationships with their patients? A very good friend, an ER physician, once shared with me the difficulty in contacting patients when concerning incidental findings are found during ER visits. Since EMTALA requires all people entering an Emergency Department be seen regardless of their ability to pay, many patients (mostly the uninsured) will use the ER, give fictitious contact information, get care, and flee before questions are asked. When the ER physician looks over lab work, or when culture results returned, or when films are read by radiologists, if the results differ from the physicians initial impression the ER physician will make a callback to that patient. More often than not, the ER physician will learn that the contact information is incorrect and there is no way to contact that patient with the results. This creates a real quandry for the physicians and is detrimental to the patient. On the up side, these patients would likely not bring a lawsuit since they would have to admit that they gave false information in the first place.
Let’s not get distracted. The major issue in poor follow up is lack of ability to pay for the visit. Give everyone health insurance first, then we’ll see who is falling through the cracks.
“But should patients who intentionally don’t followup, or shun medical advice for ineffectual alternative therapies, be completely blame free?”
Absolutely, unequivocally patients (unless of course they lack capacity which is a small minority) should shoulder responsibility for their own care. Doctors can only do so much, and there are only so many resources that can be devoted to ensuring the patient the patient follows up and carries out his/her recommended treatment plan.
We can argue over what percentage of responsibility falls where… but, for the vast majority of people need to take ownership of their health. A physician may have thousands of patients to care for…although, we do our best as physicians to ensure patients follow up with their appointments, go to the consultants recommended, take the medications prescribed, obtain imaging studies requested… it is unfair and unreasonable that a physician should take 100% responsibility if some ‘intentional neglect’ on a patients part leads to a missed diagnosis.
DocbLawg – “……A primary care physician, as a guardian and gatekeeper to a patient’s care…..[has some sort of special or increased responsibility to follow-up]…..”
I don’t accept the premise. Many people walk into my office, who have self-referred to a cardiologist for simple hypertension, an orthopaedic surgeon for a simple sprain, an obstetrician/gynecologist for PAP smears, gotta have that female gynecologist thing ya know. Well, the PAP is done by that GYN’s midlevel, but anyway…….
I love it when they end up billing consultation fees for these services, when I didn’t make any such referral, wouldn’t refer for simple hypertension or simple sprains or PAP’s, wasn’t even told about the problem in the first place, find out about the matter after the fact. Maybe just as well that the codes are being phased out.
They end up coming to me for some problem that falls through the cracks. Is it my responsibility to make sure the patient followed-up on that abnormal PAP? How about the mammogram? Usually, the GYN has addressed that. Or DID the GYN address it this time? Not that I have the results.
I take personal responsibility for all my health care. I make sure I receive results from every test, make sure I understand what the results mean and decide what the best course of action based on the results.
Sometimes I make the decision not to follow-up. I am solely responsible for my care and I can’t rely on a hurried doctor to make the right decisions for me.
Which is great, and the way it should be. I do emphasize to patients, if they have not received results of tests from me in one week, to call. Never assume that no news is good news. It’s too easy to drop the ball. “You have kids? Do your kids always give you telephone messages?”
Mom rolls her eyes in understanding. We can drop the ball. I tried to call a patient yesterday, their number is changed and they didn’t update with me. And yes, certainly, the doc’s office can drop the ball as well.
Not sure if courts always hold people to the degree of individual responsibility you assume.
I agree with Dr Prince (and disagree with Dr Green).
How many patients take their blood pressure pills and then stop, after checking their BP and find it now reads “normal.” Pharmacies make patients sign off on all RXs – and give explanations on how to take the RX.
The problem is we are migrating more + more to a society w/o personal responsibility. This post is really a first cousin to the litigation issues/tort reform problem we are facing.
Lawyers are in effect, anti personal responsibility; otherwise, no one to sue. It is always someone elses fault. Many problems can be solved with effective tort reform – and the Safe Harbor concept introduced by Rep Price of GA is a great first step.
ninguem – you are precisely the type of doctor I would want to defend. It seems you are proactive in your patient’s care only to be stifled by insufficient communication from your patients to keep you “in the loop” so that you can give them your best care. My comment was focused on that very problem and I agree that a patient needs to be proactive in their own care. In terms of the gatekeeper comment, you are only as good a physician as the information you get, that includes the information you get from your patient. If the patient doesn’t provide you with important information from another clinician and you are unable to fully analyze the clinical picture, I don’t believe your peers or a jury would hold you responsible. Maybe I’m crazy but I still believe in the jury system and in my experience the jury will expect the patient to be responsible for their own care in the scenario that you discuss.
The further we push the paradigm toward a requirement to practice perfect medicine, the fewer practitioners will be willing or available to provide such care.
We can’t sue our way to better health care.
There is not now nor has there ever been a requirement for perfect healthcare. The vast majority of medical errors do not even result in a claim to an insurer, much less a lawsuit. And the vast majority of cases tried to a jury result in a finding for the doctor. Clearly society is not requiring perfection from physicians.
Evinx is off base in that he doesn’t understand that a trial or lawsuit is all about personal responsibility. It’s just the two parties to it can’t agree on who should be responsible.
I absolutely reject the premise that I am under any obligation to be my patient’s mother. I give them the info. I make every effort to make sure the patient understands it sufficiently. I emphasize it if it warrants it. Then the patient does what they want. If that results in a bad outcome, then I feel for them, but I do not accept responsibility for their choice.
patient’s mother isn’t the standard. However, failure to inform the patient of abnormal results, ignoring results, failing to take an adequate history, do an adequate exam, dismissing patient complaints can lead to unecessary errors that really are the doctor’s fault.
The patient can’t know all you need to know. You are the expert. You must listen. You must ask the right questions.
Comments on this entry are closed.