The High Cost of Hanging Up Before Conveying Test Results

Conveying test results to patients is important. Conveying test results that need to be acted on immediately is essential. But what happens when you encounter difficulty getting through with the results? This month’s case examines that situation.  

Clinical Scenario

The patient was a 31-year-old mother of two. She went to see her primary care physician at her HMO with concern of pain in her ankle and calf. After an examination and a discussion with the patient, the PCP suspected that she might have a muscle tear in her calf, and he referred her to a radiology practice for radiographs of the ankle and Doppler ultrasonography of her calf to be performed the next day. He scheduled a follow-up appointment with the patient for the end of the week.

The patient went for her radiology appointment the following day. The radiography and ultrasonography procedures were conducted by a radiologic technologist. After she left, the tech brought the ultrasonogram to the diagnostic radiologist to read.

The tech was frowning as he brought it to the physician. “Something looks off here,” said the tech to the doctor. “I suggested to the patient that she should probably call her doctor.”

The radiologist reviewed the images and diagnosed deep vein thrombosis that put the patient at risk of pulmonary embolism. He immediately picked up the phone to call her primary care physician so she could be treated immediately. He initially reached the automated phone system of the HMO, but after working his way through the choices, he was able to reach an operator. The radiologist explained to the operator that he needed to speak to the PCP urgently about test results. The operator responded that she would have to locate the PCP, and she put the radiologist on hold.

Time seemed to stretch out interminably as the radiologist waited. Finally, he began hitting buttons on the phone, hoping to get someone. “Hello! Hello!” he yelled into the receiver, to no effect. Finally, in frustration, he hung up the phone. Rather than call back, he prepared a fax with the information and a diagram of the patient’s calf indicating the problem, and gave it to an assistant to fax to the PCP.

Meanwhile, the patient called the PCP’s office, as suggested by the radiologic technologist, but was told that her results weren’t in yet. She did not show up for her appointment at the end of the week and was found dead at home a day after the missed appointment. The cause of death was a pulmonary embolism.

The patient's distraught family hired a plaintiff’s attorney and sued the radiologist for negligence.

The Trial

The case went to trial. The first witnesses for the plaintiff, the patient’s parents, testified that she was a single mother, raising 2 children on her own and putting herself through school at night. The next witness was an expert physician who testified about the life-threatening nature of deep vein thrombosis, and how it can often be successfully treated with blood thinners to avoid a pulmonary embolism.

The plaintiff’s attorney questioned the expert about this. “Had the patient been informed of her condition and put on blood thinners at once, do you believe the outcome would have been the same?”

“No,” said the expert. “In my experience, if deep vein thrombosis is caught and treated, a pulmonary embolism would be avoided. The patient should not have died from this. Not when there was evidence that she had deep vein thrombosis, and that evidence could have been acted on.”

The plaintiff’s attorney then called the primary care physician.

“Did you receive a phone call from the radiologist informing you of your patient’s urgent condition?” asked the attorney.

“No,” said the PCP.

“Did anyone on your team receive such a call?”

“No.”

“Did you or anyone on your team receive a voice mail from the radiologist?”

“No.”

“In your experience, when there is a positive finding of deep vein thrombosis on an ultrasound, what generally happens?”

“I’m usually notified immediately by the radiologist by phone.”

“And did that happen in this case?”

“No.”

The PCP went on to say that if he had been notified, he would have had the patient come to his office or the emergency department immediately and started her on blood thinners. This would probably have saved her life, he said.