I recently published a note about turmoil arising around the Kaiser CIO and their EMR (link here) but I have been surprised about the number of stories surfacing on the web concerning medical mishaps within that health system as well. For example, here is a link to a site called KaiserKills. I also came across an article describing a missed diagnosis relating to lab reporting that I want to discuss in greater detail. Here is a link to the story and below is an excerpt from the it (boldface emphasis mine):
Draining the life out of Jesus Gaytan was prostate cancer. But he didn't know it because his doctor ignored the symptoms of his cancer for years and then failed to review tests results that warned of the disease, according to an accusation filed against the physician by the Medical Board of California. By the time the cancer was diagnosed, it was terminal....Laboratory technicians did not notify Lamantia [the patient's physician] of the abnormal tests....Instead, the results were entered in Gaytan's central medical file, where records are permanently stored, Iungerich [the patient's attorney] said. In early 2002, Lamantia ordered a blood test called a PSA....The PSA level was 23....The doctor's records suggest she never reviewed the tests or referred Gaytan to a specialist....Four months later, in June, another blood test was performed. The PSA level was much higher, at 52.... Again the doctor did not note the results, according to the accusation. But Lamantia had no way of knowing Gaytan needed further care, her lawyer said. The protocol at Kaiser is for the lab to notify doctors of abnormal tests, Iungerich said. When the lab does not call, doctors are not aware there is a problem, he said.
Understanding that some a portion of this story consists of quotations from the patient's attorney, this is a sad commentary about the way that lab reporting is presented to the general public . For example, the incorrect assertion is made that a physician has no way of knowing whether a patient has a problem unless the lab calls the physician. This totally ignores the standard lab reporting process to physicians.
For me, the most interesting and challenging question raised by this story is the following: Under what conditions is a clinical lab required to provide notification to clinicians beyond routine reporting. In other words, given that it is the professional obligation of all clinicians to review and take action on lab results reported to him/her, when is it necessary for lab personnel to directly and personally contact the physician with notification about a particular a result. Below are two situations when it is the usual practice for clinicians to be contacted directly by lab personnel:
- Critical (panic) result reporting. The rationale here, at least in my mind, is driven by the acute nature of the problem -- contacting the physician quickly and directly avoids the harm that might come about when the result is reported with the routine reporting process.
- A significant diagnosis (e.g., malignant neoplasm) is encountered in a surgical pathology specimen when, in the judgement of the pathologist, the result may be overlooked by the test-ordering clinician. The rationale here is that the clinician may be very busy and not notice a result requiring immediate attention when the presumption at the time of the procedure is that the results will be normal.
One of the critical aspects of this story is whether a high PSA should be considered as a critical value from a lab reporting perspective. A high PSA does not constitute an acute medical emergency but it certainly qualifies as a critical value. Here is one opinion about this specific question:
...[T]here are a number of similar tests for which it is imperative to share the results quickly, and to do so in a way that ensures that the appropriate “connection” is made to the clinician who can order immediate action. Some test results should always be immediately communicated to the practice... Other results just need to be specifically communicated to someone in the practice, perhaps by e-mail or fax, for review next time the office is open. Examples include detectable PSA in patients with previous undetectable PSA (i.e., a man who has had a prostatectomy)....All of these test results may be critical to patient safety, but their results do not trigger the “critical value” alerts already built into the lab reporting system.
That Kaiser Kills links list is a very old mirror from the KaiserPapers site - many of the links may be broken at this point. I have a much more extensive web collection on my blog here:
http://www.livejournal.com/tools/memories.bml?user=corphq
This is also out of date by about a year. The reason is that there are a *lot* of these stories on the web, and especially on blogs, and it became overwhelming to track them.
Thank you for taking the experience from the patient point of view seriously. I think many doctors are just dismissing anyone with a complaint as a "problem patient."
Posted by: gadfly | November 12, 2006 at 01:59 PM