With the complexity of today’s healthcare environment, a pathologist may need to take a more active role in coordinating diagnosis communication than what may have been standard in the recent past. In the following case, the patient was never informed of a final diagnosis of malignancy after being informed the preliminary diagnosis was benign. Consider how the pathologists could have changed the outcome in this case.
The pathologist’s failure to notify the ordering physician of a cancer diagnosis delayed treatment and worsened prognosis.
CT scan revealed a mass in the patient’s liver. The gastroenterologist ordered a liver biopsy, which was completed by a radiologist, who sent the liver sample to pathologist #1. Pathologist #1 suspected hemangioma (a benign tumor), but he did not feel the biopsy was clearly diagnosable. He sent the specimen to pathologist #2 for further evaluation, and reported his preliminary findings to the gastroenterologist, who reported them to the patient and scheduled a six-month follow-up appointment. Pathologist #2 diagnosed adenocarcinoma compatible with cholangiocarcinoma, and sent a report to pathologist #1, who assumed pathologist #2 had communicated the results to the patient’s other physicians. No one informed the patient of the cancer diagnosis. The patient, believing her liver mass was benign, cancelled her follow-up with the gastroenterologist. One year later, the cancer diagnosis was discovered. By then the patient’s cancer had metastasized and was inoperable. The patient sued the gastroenterologist and the two pathologists for the delay in diagnosis and treatment.
Experts were in disagreement over which pathologist should have communicated the cancer diagnosis to the gastroenterologist. However, there was general agreement that, at a minimum, one of them should have informed the gastroenterologist and primary care physician (at the least as a matter of professional courtesy). If pathologist #2 had called the gastroenterologist or the primary care physician and informed either one that she had discovered malignant cells, the patient could have obtained necessary treatment and she most likely would not have filed a lawsuit. Experts were critical of the gastroenterologist for failing to follow up on the results.
A physician who performs a biopsy or other procedure may not be further involved in the patient’s care and treatment. Sending a pathology report only to the last person in the treatment chain may result in a treatment delay. Consider the following recommendations:*
Pathologists
Administration
More information about follow-up systems in general, including sample forms to facilitate effective follow up, is available to NORCAL policyholders in the NORCAL Risk Management resource, “Follow-Up.” Log in to MyACCOUNT or contact NORCAL Risk Management.
* Raouf E. Nakhleh. “Quality in Surgical Pathology Communication and Reporting.” Archives of Pathology & Laboratory Medicine. 2011;135:1394-1397. DOI: 10.5858/arpa.2011-0192-RA