When I follow up, I don't give up

August 4, 2006

It's a mistake to think all the responsibility for subsequent care rests with the patient, says the author. She has a case to prove it.

I was attending another risk-management seminar. The room was full of physicians who seemed more concerned about where their responsibility ended than about serving their patients.

"Do I have to have the patient in for follow-up on every abnormal test result?"

"If I've told a patient to call in the next day and he doesn't, am I responsible?"

"How much baby-sitting do I have to do?"

The risk-management consultant, an attorney, asserted as usual that the liability for follow-up is ours, and he urged us to develop office systems to make sure patients don't fall through the cracks.

Also as usual, I sat there smiling, while my colleagues tried to stump the experts with circumstances so extenuating that maybe they wouldn't be held to account: "If the patient leaves the country? If I've phoned and sent two letters? How about three letters? What if I think the patient has transferred to a colleague? When am I off the hook?" Mostly, I was smiling because I remembered Maureen. Maureen's not really her name. But she was the patient who confirmed for me and my staff that it's essential to be persistent in follow-up, and that liability isn't the most important issue.

It has always been my office policy to call patients about lab results, to check their progress in treatment, to make sure they get the right subsequent care. When an abnormal report comes from the local emergency room or urgent care center, my nurse calls the patient.

"Your potassium was low in the ED last night. Are you taking your medication? Did they give you anything new?" Or, "Your urine culture at the clinic was positive. Is the prescription they gave you working? We need to schedule an appointment to check it again when you've finished the bottle." I do it because it's good medicine. It's also good marketing: My patients love the attention and care.

My staff, on the other hand, sometimes hates the hassle. They have plenty of work in my busy family practice, without tracking down what the ED did last week for Ruth, whose blood sugar was over 300, and who hasn't been in for a refill of her medication. We call her and make an appointment to check her out.

My nurse is busy enough without calling Cindy for the fifth time about her atypical Pap. Cindy skipped her last appointment and hasn't returned the messages we left on her answering machine, or the one we gave her husband. "Can we file it?" my nurse asks. But Maureen keeps us on the straight and narrow: Cindy gets a certified letter asking her to call or come in.

Any of these patients could be another Maureen. Her problem first came to my attention one March, with a treatment report I got in a big batch from a local urgent care center. A doctor there had seen her two weeks earlier and diagnosed Bell's palsy. He didn't initiate treatment or refer her to a neurologist. Instead, he told her to see me the next day. But she still hadn't called.

Since Maureen was in her early 30s, I felt she had no business getting Bell's palsy. I got excited thinking about the workup I'd have to do on an isolated peripheral neuropathy in a young woman. Lyme disease was on everybody's top-10 list that year, and there was always the possibility of HIV infection. But first we had to get in touch with Maureen.

Well, we tried. My staff called and talked to her answering machine, sometimes as many as four times a day. We sent three first-class letters to her home. Weeks went by. Finally, we sent a certified letter, which did bring Maureen to my office.