When I entered practice in 1976, I began with the philosophy that if a test was important enough to do for my patients, its results were important enough to report to them — even if the results were normal. I thought about how I might be the one anxiously awaiting the results of a test performed to define my health status. With more than two decades' experience and the coming of managed care, my philosophy hasn't changed. But I've learned some lessons along the way.
In the beginning, we telephoned every patient with his or her test results. Limits on physician and staff time quickly changed that, and "normals" were sent a postcard instead. The information related was rather generic, but some female patients began to complain that the postman would know when they had a Pap smear performed. (This was before commercials for menstrual pads became commonplace on TV.) When enough patients complained, we switched to closed envelopes.
I developed note form A with a carbonless copy attached. By means of listed categories with boxes to check, it relates the information I need to give patients on normal tests. It also permits me to communicate simple recommendations, or to enclose a follow-up prescription — thus possibly avoiding the need for an office visit. The carbonless copy provides malpractice protection for me, and also allows me to confirm to patients that I did indeed provide instructions when they forget, or insist that I failed to do so.
I make a habit of completing these note forms personally. While taking minimal time, this keeps me in touch with the communications my patient is receiving. (I also sometimes add a sticker, as shown, for a lighter touch.)
Two kinds of test results, I've found, lend themselves to special forms of their own. One is the glycohemoglobin (hemoglobin A1C) or "GHB" test. All diabetics have an HbA1c routinely every three to four months, avoiding a monthly visit for diabetes control surveillance. Handout B explains the test and lets the patient compare the current result with the preceding one. It also presents pertinent information about activity and calorie intake control that can help to promote compliance.
Form C puts lab results for cholesterol, triglycerides and high-density lipoproteins in context for patients, explaining not just desirable cholesterol levels but also the importance of the cholesterol/HDL ratio. It also includes a place to characterize the patient's overall risk of heart disease and three lines on which to spell out recommendations for future care and life style choices.
With my system, I am able to recall patients for future visits by adding a note in red to my staff. A recall card is prepared and placed in a calendar box. At the beginning of every month, these cards are pulled and mailed as reminders. A notation is made in the chart at that time that a card was sent.
All of this may not be rocket science, but in the face of recent research suggesting that many physicians do a poor job of communicating test results ["Patient Notification and Follow-up of Abnormal Test Results," Arch Intern Med, Vol. 156, Feb. 12, 1996] I believe the forms I've developed may provide a helpful model, helping practices to improve the patient satisfaction scores that managed care organizations study carefully and to assure the documentation necessary these days for legal protection.
I instruct all patients for whom I order a test to expect to hear from me, one way or another. If, within two weeks, a note or call is not received, they are asked to call the office to investigate. That allows us to track lost or delayed test results. It also forces me to review labs and other services on a timely basis. I tell patients: "Do not assume the test is normal if you have not heard from me. Assume I have not seen it and it may have been lost."
All lab tests are drawn in my office to avoid the lost order or failure on the patient's or lab's part. All ancillary studies and specialty consultations are specifically ordered by my staff, and the times are noted in the medical record. The patient is left only with the obligation to show up.
The wisdom of our approach was brought home to me one day when I was in a large, busy hospital emergency department and happened to overhear a physician giving directions to a patient. "Go to the XR department and get a brain scan," he said. Then he moved quickly to the next room, leaving the patient standing there, obviously wondering where to go and whom to ask.
"Quality" is a much-voiced goal in health care delivery these days. Surely two indispensable features of quality are making sure patients get the information they need and making sure they can understand it once they get it.