Issues and challenges in test follow-up

Canadian doctors mostly work in an environment where the physician who orders a test is accountable for its follow-up. That makes sense, of course: presumably a clinician orders a test because they want to know something. But even that basic rule can lead to problems as was discussed at the Family Medicine Forum in Montreal. During a session on medico-legal tips, one physician asked what a doctor should do if they worked somewhere but then leave and no longer have access to the EMR needed to perform a followup? The physician said she works in different provinces and after leaving she sometimes can’t access test results and has never given any clear instructions on what to do. “(The college) says, ‘well, you are still responsible.’ But there’s zero way. I tried multiple avenues.” She even asked if the results could be forwarded to her but was told “we can’t do that.” Dr. Katherine Larivière, one of the CMPA physician advisors leading the panel, said: “The only thing that you can really do to prevent those scenarios from occurring, is prevent them ahead of time. So negotiate that in your contract: that someone will be following up on those results for you. And we always hope that you get that in writing—that can be in an email—but that you have that somewhere black on white, that you have an agreement that someone will follow up on your results.” Read: Dr. Jabir Jassam: CPSO: Thank you Dr. Larivière said, “most colleges are clear that if you order the test, you follow up on the test and that is your responsibility.” Indeed, she added “the college in Ontario has recently come out with a bit of clarification that really highlights how it’s the ordering physician that’s clearly responsible for following up on any test that they order.” So, doctors are responsible once they order a test to follow up or at least to effectively ensure that someone else is following up on it for them, she said. “And an ‘effective delegation’ of that task isn’t just sending a letter saying, ‘I expect that you will follow up on this.’ It would involve two-way conversation.” But do you have any responsibility if you are carbon copied on a test you didn’t order? No, Dr. Larivière said. “However, if you are aware of the test and you think it needs action, it would be the professional thing to do to ensure that that action is taken. So, what you do might depend on what kind of test it is. We use an example of a normal CBC. It might require a different action from you than a CC that you received on a skin biopsy that shows a positive melanoma. So, most of the time it’s somewhere in the gray zone in between those two extreme examples.” Reasonableness Dr. Larivière talked about just how much is “reasonable” for doctors to do in following up on test results and when they might get in trouble if something is missed. “Who’s going to decide whether or not you went far enough in following up on a test result or establishing your follow-up system?” Dr. Larivière said. “Well, it’ll be your peers. It’ll be colleagues who are called on as experts by the college or by the courts to comment on your care. And the standard—what you’re measured against—is what a reasonable physician with similar training and under similar circumstances with you (would do). A rural physician providing care in the emergency department with family medicine training won’t be held to the same standard as a physician providing emergency care with a five-year specialty in emergency medicine in a tertiary care health system with access to all of those resources. So, some physicians do find that reassuring that you have to do the best you can given the situation you’re in and what you’re able to do given where you are.” Because the panel was specifically targeted for first five-years-in-practice clinicians, she also underlined how important it is that doctors be familiar with the followup process for tests or consultant reports where they are working. “So in your first five years of practice, you might find yourself working in a number of different environments (and) in different hospitals with different processes. Some are on paper, some are EMRs. You use different EMRs. You’re in a community clinic, maybe doing emerg work or other work. There might be a dozen different systems that you’re working with. So try and be as familiar as possible with the system you’re working in—(it) can really be helpful to try and avoid those hiccups where things fall through the cracks that you didn't even know existed.”

Issues and challenges in test follow-up

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