dialogues in healthcare - the rozovsky group...these cells play a different role in the digestive...

Dialogues in Healthcare © 2016 All Rights Reserved

Dialogues In Healthcare STRATEGIES FOR EFFECTIVE COMMUNICATION

Volume 10 Number 2 February 2016

The Importance of the Post-Diagnostic Test Discussion Each day, care providers across the country carry out intrusive diagnostic procedures to help determine the cause of patient ailments. Although many of these procedures involve risk, the potential benefit of accurate, timely diagnoses can provide the context for life-saving treatment. As a case example demonstrates, the benefits of such diagnostic interventions can be of little merit if the results are not explained in a clear, unambiguous way with patients. The Case Study. A 48-year-old business executive saw his family physician with a complaint of recurrent indigestion. The executive told the physician that he would awake with indigestion, and at other times, he would have heartburn with a feeling of pain in his throat. Initially, he had tried over-the-counter heartburn medication, but he decided that when it failed to stop the problem, he should see the physician. The physician ordered some prescription medication for the business executive. He also recommended a change in diet, including the avoidance of alcoholic beverages, caffeinated products, and fried foods. The patient was asked to return in a month for a follow-up appointment. During the next visit, the patient report that while the frequency of heartburn and indigestion had diminished, he still had a sour taste come up in his throat after he had eaten some foods. He also reported having bouts of a frequent cough.

A Publication of The Rozovsky Group, Inc./RMS

Fay A. Rozovsky, JD, MPH Editor

POWERED BY ONEBEACON PROFESSIONAL INSURANCE


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The physician decided that it was time for the patient to see a GI specialist. The physician said, “I think you have gastric reflux, the backing up of gastric acid into the esophagus. The specialist will probably conduct some tests to determine if it is gastric reflux.” After taking a detailed personal and family history, the specialist told the patient that he might have something more significant that gastric reflux. “From what you have described, it is possible that you have something called Barrett’s esophagus. Basically, this means that after frequent contact with stomach acid the lining of the esophagus is changed to the point that it becomes similar to cells found in the intestine. These cells play a different role in the digestive tract and there is a risk that this transformation of tissues can lead to cancer of the esophagus. I recommend that we do a test now to determine if you have this condition,” said the specialist. “What is involved in this test,” asked the patient. The doctor explained, “The test is called an upper endoscopy. We give you some sedation and then pass a tube down through the esophagus. The tube has a camera on it that allows us to examine the esophagus and the upper portion of the GI tract. We can also take small tissue samples for a pathologist to review. The test does involve some risks, including causing a hole or tear in the esophagus. This can be a serious problem. However, it is not a frequent problem.” The patient agreed to the test. During the procedure, the specialist did collect tissue for pathology. The procedure was completed without any complications. A few days later, the GI specialist received the pathology report. It confirmed the suspicion of Barrett’s esophagus. The specialist sent an electronic copy of the report to the patient’s family physician. The specialist called the patient and told him about the results. The specialist said, “It looks like your problem is linked to your gastric reflux so you should continue taking the prescription medication and continue on the recommended diet. Let me know if your condition becomes worse. We shall see you in a year for a repeat test.” Following his telephone discussion with the patient, the specialist documented in the patient’s record, “Pt. advised to follow diet and medication plan. Patient asked to get an appointment for a follow-up exam and EUS.” About 10 months later, the patient called the specialist’s office to schedule an appointment. He was told that the GI doctor was on medical leave and that the first available appointment was in about six months. “Are you having any symptoms? Any problems? We could refer you to another doctor, but if you are



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okay, waiting should not be a problem. Actually, you might wait even longer if I try and get you set up with another specialist,” said the scheduler. “I am about the same,” said the patient. He continued, “When will I see the doctor?” The scheduler gave him a date seven months later. When the patient saw the GI specialist he told him that he had started having problems in the previous eight weeks. “The heartburn has come back along with the cough. When I eat certain foods I notice that it is difficult to swallow, too,” said the patient. “You should have called me,” said the specialist. “Well your office said that you were on medical leave and the person who scheduled my appointment told me that it should be okay to wait to see you,” said the patient. The specialist got the patient scheduled for a repeat upper endoscopy later that week. A biopsy sample revealed esophageal cancer that required extensive surgery. The patient died a year later. A wrongful death lawsuit was filed against the specialist claiming negligent failure to properly instruct the patient regarding his post-test treatment options. An alternate theory of claim involved negligence for the specialist’s failure to provide appropriate medical management for Barrett’s esophagus. Observations on the Case Example. Discussing the results of diagnostic tests is an important component of care provider-patient engagement. When a test results identifies the patient as being “at risk” for cancer or another serious ailment, it is incumbent upon the care provider to explain risk factors and practical steps that the patient should follow in the future. It is not uncommon for well-intentioned care providers to say to a patient, “See you in six months” or “See you in a year.” Similarly, it is not uncommon for care providers to tell a patient, “If you have a problem call me.” How is such information processed by the patient? Does he or she interpret the “see you” as the care provider assuming responsibility for booking a follow-up appointment? Or, is it a situation in which the patient believes he or she is



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responsible for booking the next appointment? If it is the latter and at check out the receptionist says, “Oh, our computer is down, please call us to schedule your next appointment,” how likely is it that the patient will remember to make that telephone call or attempt to book it via an online scheduler? Sometimes a scheduler may say, “Oh, our calendar does not go that far out for setting up appointments. Please call me us in three months.” Once again, how likely is it that the patient will remember to do so? In the business executive’s case he did attempt to book the repeat visit. However, the physician was on medical leave. The patient was given the option of a referral to another specialist, but was dissuaded from doing so by what the scheduler said to him:

“We could refer you to another doctor, but if you are okay, waiting should not be a problem. Actually, you might wait even longer if I try and get you set up with another specialist.”

When the patient began experiencing problems, he did not attempt to contact the specialist. The reason was that when he called to make his follow-up visit, he worked on the information provided by the scheduler, namely that

“the doctor was on medical leave and that the first available appointment was in about six months.”

Perhaps the patient did not know that when a patient called with a problem, an urgent visit could be “fit into” the care provider’s schedule. There is another communication issue in this case example. In a telephone discussion of the results, the specialist told the patient to let him know if the condition became worse. He was encouraged to follow his medication regimen and diet. But the patient was not advised about the serious nature of Barrett’s esophagus and why it was important to “speak up promptly” should his condition become worse. The medical record entry amplified this issue. Indeed, the physician’s entry said nothing about the patient calling him if his condition became worse. Instead, there was a brief note in the medical record to the effect that

“Pt. advised to follow diet and medication plan. Patient asked to get an appointment for a follow-up exam and EUS.”

Along with the fact that the patient was acting on the assumption that the doctor was “unavailable,” the case demonstrates what can happen when there is a series of disconnects in post-diagnostic test planning for continued care and follow-up.



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Strategies for Post-Diagnosis Testing and Follow-up Discussion. Post-diagnostic testing follow-up merits a thoughtful discussion between a care provider and patient. Important components of such a dialogue may include the patient reporting new or recurrent symptoms and the importance of scheduling future office visits and repeat diagnostic testing. Strategies for such a discussion include the following:

1. Follow the Elements of an Informed Post-Diagnostic Discussion. Incorporate key components in the discussion with the patient regarding findings from the diagnostic test. Include follow-up instructions for the patient and work with office personnel to schedule a time for the recommended follow-up visit and necessary diagnostic testing. [See Sample Tool]

2. Provide Useful Post-Diagnostic Testing Instructions in Written or

Online Format. Furnish patients with post-diagnostic testing information that can be used to help them better understand their medical issue and when it is prudent to contact the physician. Think about making such information available on the practice or clinic website, on demand through the patient portal, or in hard copy. Make certain that the content meets recognized health literacy standards.

3. Consider Interim “Wellness” Checks by Telephone or via a Patient Portal. Think about implementing a “follow-up” system whereby a nurse can check in with at risk patient during the time interval between past and scheduled tests. Take advantage of practical communication technologies such as telephone messages and information communicated by the patient portal. Instruct staff to take prompt action to schedule an office visit when responses are indicative of an at-risk patient experiencing recurrent or new symptoms.

4. Anticipate Scheduling Issues that May Arise for Follow-up Appointments and Testing. Build into the scheduling process flexibility such that a prompt, follow-up visit can be scheduled for an at-risk patient manifesting recurrent or new symptoms. Reiterate with staff the importance of creating an appointment for such patients rather than personnel taking it upon themselves to “judge” whether or not the patient needs to be seen promptly.

5. Complete a Patient “Teach-Back” for Follow-up Instructions. Use a “teach-back” process to confirm that the patient understands the



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meaning of diagnostic procedure results and the need for follow up testing. Use the process to confirm that the patient understands the importance of contacting the care provider when there is a recurrence of the underlying problem or the appearance of new symptoms.

6. Document the Post-Diagnostic Follow-up Discussion.

Make a complete entry in the medical record about the post-diagnostic test results discussion with the patient. Include a summary of the findings and the meaning of the results as well as the importance of adhering to the agreed-upon care plan. Note in the record the date scheduled for a follow-up office visit and a repeat diagnostic test. Incorporate in the entry that the patient was given resource information (if applicable), the title and version number of same, and the link to website intended for patient use. Document that the patient was encouraged to contact the care provider if there is a recurrence of his or her underlying condition or new symptoms.

Conclusion. Following receipt of diagnostic testing results, careful thought should be given to what to discuss with patients who are “at risk” for cancer or other serious ailments. Setting realistic expectations is important. Care providers should empower patients to “speak up” about the need for interim appointments, reporting new symptoms, and following agreed-upon treatment plans. At the same time, well-intentioned office personnel should not give “advice” that is contrary to the “game plan” outlined by the care provider with the patient. Making useful resources readily accessible can help reinforce the expectations in the care plan agreed upon between the care provider and the patient. Such a step can help reinforce the important “take-aways” from the post-diagnostic test discussions between care providers and patients.

DDIALOGUES IN IALOGUES IN HHEALTHCAREEALTHCARE is a publication of The Rozovsky Group, Inc./RMS. This publication is not intended to be

and should not be used as a substitute for specific legal advice. For additional information on consent to treatment, refusal of consent, and patient-provider or provider-provider communications, please contact us. Contact Information: The Rozovsky Group, Inc./RMS, 3231 Reades Way, Williamsburg, VA 23185 Tel: (860) 242-1302.



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Sample Tool

Informed Post-Diagnostic Discussion

This sample document can be modified to fit the needs of a specialty practice. The intent is to provide a checklist to facilitate dialogue with a patient subsequent to a diagnostic procedure that indicates that the patient is at-risk for cancer, coronary artery disease, or another serious ailment. ¨ Determine if language interpretation services are needed for the

discussion and obtain such language services as needed. ¨ Explain the results of the diagnostic procedure. ¨ Explain what the results mean to this patient. ¨ Discuss with the patient treatment options that are based on the results of

the diagnostic procedure. ¨ Discuss with the patient medication management. ¨ Discuss with the patient dietary changes that are indicated. ¨ Be candid about necessary lifestyle changes that may be warranted, based

on the diagnostic test results. ¨ Talk about the patient’s concerns as a result of the diagnostic test results. ¨ Talk with the patient about his/her preferences, including obtaining a

second opinion. ¨ Encourage the patient to include in the discussion his/her spouse, partner,

family member or trusted friend as such an individual may provide useful observations and can support the patient’s efforts with medication management, dietary changes, and lifestyle adjustments. Discuss with the patient the potential consequences of not managing his/her “at risk” ailment through medication, diet, and follow-up diagnostic testing.

¨ Tell the patient where he/she can find useful information about his/her condition, including in hard copy documents furnished by the practice or clinic or on reputable websites.

¨ Ask the patient if he/she has any questions and provide understandable answers.

¨ Discuss reasonable expectations going forward. ¨ Conclude the discussion with a “teach-back” to confirm patient

understanding.

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