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Leaving any aspect of patient care to "chance" seems almost crazy, doesn't it? Indeed, most would argue that no physician worth his or her salt would do such a thing. But in reality, many of you do just that day in and day out when you rely on the patient to schedule a follow up appointment or to initiate rescheduling after missing an important follow up visit."A gamble?" you say. "How can that possibly affect me? If the patient doesn't want to follow up that's her business and I am much too busy to keep track of or to be concerned with such things!!" If you find yourself thinking, much less voicing sentiments similar to these, think again. You may just find yourself facing suit over the death of a patient!! As the following case study illustrates, sometimes just a simple phone call from the physician can prevent a horrible outcome for the patient and the practitioner.

The 73 year old patient was seen by his primary care physician for a routine physical examination on June 9, 1997. Among the studies ordered and or run at that time was an EKG. Because the patient's EKG showed a slow heart rate, the PCP referred him to a cardiologist for evaluation of that condition.

The patient saw the cardiologist on only one occasion, June 19, 1997, although a follow up visit was planned at the conclusion of that interaction. During the evaluation, the cardiologist performed an exercise tolerance test, ordered laboratory testing, and recommended evaluation of the heart by use of a Holter monitor. He also ordered a chest x-ray to be taken to evaluate heart size.

The cardiologist advised the PCP of his findings and his plan via a letter dictated on the day of the work up.The chest x-ray was taken on that same day as well, at a local imaging center, and a report was dictated and faxed to the cardiologist on the following day. Incidental to the evaluation of the heart size, the radiologist noted the following within his report:

"2.5 by 3.5 centimeter in diameter mass at the right lung base, neoplasm versus pseudotumor as described. Comparison with prior studies would be most useful. If unavailable, then further evaluation with CT scan is recommended." Although the faxed report was directed to the cardiologist as the ordering physician, it reflected that a carbon copy was also sent to the PCP's office.

The cardiologist received and reviewed the report as evidenced by his initials on the record but he did not telephone the patient or the PCP to discuss the findings relative to the heart size or the lung mass. Rather, he believed that it could wait until the patient returned to his clinic to discuss the results of the testing that had been ordered. His reasoning, in part, was that the heart was normal in size and that the lung lesion was an incidental finding unrelated to his consultation. He also assumed that the PCP would advise the patient of the same when he followed up with him since the PCP was aware of the above findings based on the notation of "carbon copy". Notwithstanding the notation of "carbon copy", the CXR report was never sent to the patient's PCP and that physician never learned of the abnormality.

Despite a notation in the cardiologist's record reflecting that the patient was to schedule a follow up visit to review the Holter monitor, laboratory, and CXR findings, the patient never returned to the cardiologist's office and was lost to follow up by the cardiologist that summer.

The patient changed primary care physicians in July 1997 when his insurance coverage changed. Dr. X took over as the patient' primary care physician and he first saw the patient on August 4, 1997, just a month and a half after the CXR report noted above.

Dr. X continued to care for the patient's primary needs and on August 3, 1999 the patient presented to him with pain in his shoulder blade. This was initially treated with osteopathic manipulative therapy. Two days later the patient returned with no improvement and a chest x-ray was taken in the PCP's office. This study revealed the right lung mass and the patient was referred to a pulmonologist for further evaluation. It was at this time that the treating physicians were apprised of the chest film done in June of 1997. When it was retrieved and compared to the 1999 study it was determined that the same mass was present, but smaller, in 1997. The patient then underwent further testing which revealed that the cancer had spread to his spine and he was diagnosed with unresectable adenocarcinoma with T9 metastasis. He underwent radiation and chemotherapy treatment for his cancer following the diagnosis but ultimately developed metastatic lesions in the brain and died in June 2001. Suit followed shortly thereafter.

The above represents just one of a myriad of cases that we have seen where, for reasons that matter little in the long run, the physician relied on the patient, or others, to initiate and or follow through on scheduled appointments. According to the experts, it is doubtful that the patient would have been metastatic in June 1997 had the mass been diagnosed and treated at that time. Consequently, if the cardiologist had called the patient regarding the findings on the chest film or contacted the patient when he missed the follow up appointment it is likely that the patient would have survived his cancer. It is certain that the physician would have avoided the lawsuit. As it stood, the result was devastating for the patient and his family and heartbreaking for a truly caring physician who would love to have the ability to move the hands of time backward just once. It is essential that you develop a method of effective follow up with patients who miss appointments; especially those who have undergone testing for which a definitive diagnosis has yet to be made.

Until next time, remember: Unless you follow up with your patients, the chances are good that you will eventually follow up with your attorney!!