Why Promptly Reporting Diagnostic Test Results Is an Ethical Duty

Clinical Scenario

You are returning to your clinic this morning after a late-night arrival from an overdue anniversary vacation with your spouse and are already behind schedule. As you enter your private office, Betty, your medical assistant, stands there with your clinical tablet for the day. You note her frown and ask, “What is the concern?”

Betty: “Doctor, we had to schedule a returning patient first because she has left several messages on our phone system wanting to be seen the moment you return to clinic.”

You: “Do you know what is troubling her?”

Betty: “No, but she said she would only discuss it with you.”

You take the clinical tablet and walk to the examination room, where Mrs. Davis awaits. She is a 67-year-old female who presented with a mass in the left parotid region with an adjacent palpable node in the pre-auricular region. You recall that she was sent to pathology for a fine-needle aspiration biopsy, but you cannot remember if you have seen the report yet.

As you step into the room, you immediately sense an atmosphere of distance from both Mrs. Davis and her husband. In your initial visit, they were friendly, albeit concerned about the mass in her parotid gland. You greet them with a smile and start to engage, but Mr. Davis begins the conversation with an accusation.

Mr. Davis: “Doctor, you did not call us with the biopsy test results as you promised.”

Mrs. Davis: “Doctor, we have been worried sick about the results. I just know it is cancer, and it has killed me now for nearly two weeks, not knowing for sure.”

You: “I am very sorry to cause you distress, Mrs. Davis. Let us figure out together what might have happened.”

Mr. Davis: “I know what happened, doctor; you just did not care enough to either call us or arrange for someone to let us know the results. That is just not right. We have not slept since the biopsy, just waiting for the diagnosis. You said you would call as soon as you knew.”

So, there it was. You knew you rushed that last day of clinic before you and your spouse sped to the airport for the trip. You usually do tell patients that you will call them with the results of a biopsy or any serious diagnostic test, so you feel you likely did the same with Mrs. Davis.

What went wrong? How do you respond to the patient and her husband? Can this be prevented in the future?

Discussion

Physician cognitive empathy is the ability to understand patients’ emotional reactions and concerns without personally experiencing those feelings. With compassionate empathy, physicians can go beyond merely understanding the patient’s perspective to providing a mitigating response that helps them, bringing actionable compassion to the situation. When an otolaryngologist has actually experienced personal emotional distress and/or anxiety from a failure to have been informed of critical data promptly, this appreciation for understanding the patient’s perspective can be quite impactful and pertinent to their professional responsibility.

When a patient is facing the potential for a serious illness—cancer, neurological disorders—the diagnostic evaluation process is normally drawn out to acquire the fundamental evidence to rule out certain disorders and rule in the true positive diagnosis. This process takes time and is often disjointed or inefficient due to many systematic or communication nuances.

The longer a patient waits for a diagnosis, the more anxiety builds up. For a usually definitive diagnostic test, such as a biopsy, a patient will consider that result to be the critical step in their evaluation, and the biopsy results will become a priority in the patient’s mind. The longer it takes for the otolaryngologist to notify the patient about the diagnosis, the more the patient’s anxiety rises, often to a critical level. Thus, timely notification of a diagnostic test result becomes a professional ethical duty.

Patients may not have the same appreciation for the frequent delays in diagnostic tests and reporting that otolaryngologists may take for granted, which supports the need for a pre-testing explanation of possible delays to guide patient expectations. Failure to understand a patient’s anxiety and respond with prompt reporting of important diagnostic test results then becomes an issue of trustworthiness and empathy from the patient’s perspective of the otolaryngologist’s professionalism.

Conversely, the patient–physician relationship greatly benefits from a physician’s understanding of the need for timely disclosure of test results. Certainly, there are reasonable, no-fault explanations for a delay in obtaining and passing along test results to patients, both systematically and occasionally. The real concern comes when there is a failure to discharge one’s obligation to patients to communicate important information promptly. As surgeons, we regularly provide a time range for the completion of a surgical procedure to the patient and family members. When that time range is exceeded, particularly by a good deal of time, we can expect family members to become worried, even deeply anxious. Indeed, “no news is likely to be bad news” in their minds. Considerate surgeons, for example, typically will request that someone on the operating team visit the waiting room to indicate why the procedure is taking longer than anticipated, and to reassure the family if reassurance is appropriate. We are all about truth-telling in our practices. This can be considered “operative empathy.”

Conveying a cancer diagnosis to the patient and family from a biopsy is another example of a duty of care. We understand that in today’s complex climate of busy clinicians, high technological reliance, and overburdens in patient care, errors of omission can occur. While not perhaps as egregious as errors of commission, these errors still can carry a high price for those who are anticipating receiving data with a corresponding explanation of the implications of the data to their clinical course. Such breakdowns and the subsequent delay in initiating the treatment pathway are additional negative implications of failure to report in a timely manner.

If we can agree that otolaryngologists have an ethical duty to report information to their patients promptly, and recognize that there are times when this is not done efficiently or effectively, how can this process be improved? Quite regularly, I hear comments from individuals that “I can’t get my doctor to call me back,” or “I was supposed to hear about the lab/imaging results last week, but no one has contacted me.” It even happens to otolaryngologists who are patients themselves.

Technological advances in healthcare delivery and systems are supposed to provide warnings, reminders, and pop-ups for efficient care of a patient. But are these systems infallible? Otolaryngologists are expected to remember to call patients to report health information in a timely manner, or at least be reminded to do so by clinic or hospital staff. Is this a reliable system?

As a general surgery resident before otolaryngology training, I always saw one of my attendings write something in a small pocket notebook after seeing a patient. When I inquired about that, he said, “This is the way I remember to do something for a patient, and it has never failed me.”

One of my colleagues, a wonderful surgeon and otolaryngologist, has always had a phone dedicated only to calls from patients, and he generously gives the number to his patients for any questions or concerns they might have. No matter what reminder system is used, it must be based on the premise that we are ethically obliged to inform patients of diagnostic findings and explain their significance, which will not only have a significant impact on their health but also on their mind, body, and spirit.

The concept of patient autonomy begs our timely reporting of information to patients so that they are fully apprised of their health status and can make meaningful decisions on that basis. Beneficence urges us to alleviate uncertainty and anxiety in patients awaiting notification of important information. The concept of nonmaleficence urges us to prevent harm to patients from delays in further evaluations for therapy planning, disease progression, and considerable psychological distress. Patient fidelity and trust in our care are, in part, related to the attention we give to communication and guidance with the conveyance of timely health information. All of these can affect the patient–physician relationship in a significant manner; we want the effect to be positive, of course.

In the case of Mrs. Davis, it may well have been that the otolaryngologist actually forgot to check the biopsy results and call the patient, did not make a note for themselves to check on the biopsy and call the patient while on vacation, or the office staff did not apprise them of the biopsy report if requested to do so. Regardless of the reason for the error of commission, there is no other viable option for the physician, save for apologizing (sincerely) and taking full responsibility for the missed communication. Understanding of the patient’s and husband’s feelings and anxiety must be projected to them, and every effort must be made to finally fully explain the diagnosis, the impact of the diagnosis on Mrs. Davis’s health pathway, and the next steps that will be taken as soon as possible.

The otolaryngologist should also allow adequate time for the Davises to explain their concerns and ask questions, and should support their perceptions through active listening and empathetic engagement for the best shared decision-making process.

Following that, the otolaryngologist would be wise to review the processes in place for timely notification of patients’ important diagnostic findings, including their own remediation and how technology might be helpful in quality improvement of notifications, adding a closed-loop process to prevent missed opportunities. Both the science and art of medicine serve to support our ethical duties and can do so in this clinical scenario.    

Dr. Holt is professor emeritus and clinical professor in the department of otolaryngology–head and neck surgery at the University of Texas Health Science Center in San Antonio.