Critical values in anatomic pathology: how do we communicate?

The following brief case summary is true. A 70-year-old woman visited a gynecologist for a routine examination. He found no abnormalities during the physical examination and obtained a Papanicolaou (Pap) smear. The slide was sent to a cytology laboratory where the following diagnosis was made: “degenerated abnormal cells of probable glandular origin present, suspect adenocarcinoma.” The report was returned to the doctor’s office where it was attached to the patient’s chart. The doctor never saw it. Eighteen months later, the patient sought care because of vaginal bleeding and was found to have endometrial adenocarcinoma with deep myometrial invasion and metastases to the para-aortic lymph nodes. She died of widely metastatic disease within 1 year. Her family successfully sued the gynecologist for “delay in diagnosis,” and the suit was settled with payment to the plaintiffs. A variety of obvious errors occurred in this case; the most crucial is the routine practice of the office that laboratory results were charted without being seen by a physician. But are there others? Certainly. Should the doctor have had a policy of review (and sign off?) on all laboratory and radiology results before charting? Should not the doctor who orders a test always check the results of said test? And most important to pathologists: Should the laboratory have notified the doctor or the doctor’s office of the results of the Pap smear? I have taken a small informal survey of some of the internal medicine physicians with whom I work and asked about their method of following up on all ordered tests for their patients. It was an eye-opening experience. Most physicians who order laboratory or radiology tests just write the orders; the patient’s insurance essentially dictates which laboratory or radiology service performs the test. Also, when the test is performed is left to the discretion of the patient and the laboratory or radiology service. So, my internist colleagues ask: When do I check for the test result? Whom do I call? Most of these clinicians have procedures in their offices wherein they sign off on all test results before they are “charted,” but there is no mechanism for this to proceed in a timely manner. What obligation, if any, does the laboratory have to communicate results? Is a signed typewritten report or an electronically verified report enough? Does the report need to be electronic only or is a hard copy necessary? Does the laboratory trust the computer system or the mail? And how rapidly must that report be received? Pathologists should be aware that many medicolegal actions against our colleagues, the radiologists, are based on failure to communicate “abnormal” results in a timely manner.1 Are pathologists the next group that will be targeted? One problematic issue is how do pathologists communicate the “critical” information? This seems obvious and intuitive. We should call or e-mail (if compliant with privacy issues) the data to the patient’s attending physician. Well, this is easier said than done. Sometimes, the physician who performed the procedure was simply a technician. A surgeon performed a lymph node biopsy to rule out lymphoma, and the node shows caseating granulomas and acid-fast organisms. The pathologist calls the surgeon who refers the pathologist to the patient’s oncologist; that physician, who does not treat infections, refers the pathologist to the patient’s internist or primary care provider, who might or might not know the biopsy had even been done! (There are