Why “Doctor Sees Results First” is harmful

Hope Leman, who just did a wonderful job interviewing me on her blog, also asked me about this quote in a previous post:

“Not only do we now have information that this rule (”doctor sees results first”) is probably harmful, we are learning that it’s probably not wanted, from physicians, who are talking to patients.”

She asked me to clarify, which I am happy to do. Below is a graphical image of what two very important studies just showed:

Failure to Notify

Hope’s question:

I don’t see how that would be harmful. Do you mean because he would then be overly persuasive and the patient would be a weaker position info possession wise?

To clarify, I did not mean that it’s harmful for doctors to see test results before their patients. Not at all. I think if a physician seeing a result and then informing the patient in a timely manner is ideal. I also think the patient seeing the result and then having a dialogue with the patient is ideal, too, relative to what is not ideal.

What is not ideal is a significantly abnormal result coming back and the patient not finding out about it, for obvious reasons.

So what I meant was, “a workflow that doesn’t allow a patient to see their test results in a timely manner is harmful.” When a system requires the doctor to see the result before the patient can, there’s a risk that the patient will never get it. When there is failure to notify, there could be failure to treat, which can be devastating.

Beyond this risk, patients and families are not demanding that their doctors see their test results first anyway, so this is just another reason to change the rule “patient doesn’t get to see their test results until the doctor does.”

The key is patient (and family) access to their own results, so they can assist in the accuracy and safety of their care. And they will do it, as I quoted previously, from the Disruptive Women in Health Care blog:

Although we may not think it’s our responsibility to read our operative report or a pathology report… it could mean the difference between a good or bad result in the best case scenario, or life and death in the worst case scenario. In the end, your health information is just that…..yours. No one will care more about it, or own it, in quite the same way as you.

I hope this explanation was better; if not, comment away!

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13 thoughts on “Why “Doctor Sees Results First” is harmful”

  1. Hi, Ted. Sorry to be dense, but doesn't this, "When a system requires the doctor to see the result before the patient can, there’s a risk that the patient will never get it…" mean that you do, in fact, want to eliminate the doctor sees it first rule?

    Just to clarify, you don't care who sees it first as long as the patient definitely gets the results?

    That is a fascinating question given the complaints of some patients that doctors sometimes (as is the case with ALS) blurt out horrible news and the fears of some doctors that some patients won't receive the proper counseling they need in such cases.

    This, "No one will care more about it, or own it, in quite the same way as you…" made me think of e-Patient Dave.

    And would you please comment on the fact that EHRs don't seem to have dramatically helped improve the rate of timely notification to patients or even notification period?

  2. Hi Hope,

    Yes, I do think the rule "the patient can't see the result until the doctor does" should probably go by the wayside, and the patient should definitely get the results.

    In the case of ALS, let me ask you back – what do you think would be better? I assume that the occasion to order a test would be because of an abnormal neurological exam. How might it be for the doctor to talk about why they are ordering tests and what they are worried about before the result comes back?

    In terms of the EHR issue – the EHR does a great thing in reliably bringing test results to the attention of doctors, it requires that there be a good workflow, though, so that every abnormal exam is followed-up on. The EHR does not usually call the patient and make sure the patient knows what the next steps are, a human does that. Allowing the patient to get the results automatically will help with that, that's the theory,

    Ted

  3. Hi, Ted. Before I address all of your comments, I want to ask you what mean here, "How might it be for the doctor to talk about why they are ordering tests and what they are worried about before the result comes back?" Do you mean here that the doctor should indeed start talking about he may be worried about (say with an MRI that shows negative for MS but which leaves ALS open as a possible diagnosis) before anyone involved has the results of the tests or do you mean that such conversations should not take at all until both parties, patient and doctor, have the rest results in hand (the patient even the night before or days before the interaction with the doctor)? Could you clarify? Isn't there a risk of self-harm by a patient in cases of neurodegenerative diseases if they are not counseled?

  4. I'd hate to see this conversation focused 100% on risk avoidance.

    Yes, we certainly need to weigh the relative risk & frequency of (a) patient finds out in an impersonal way vs. (b) patient never gets notified. I'd also like to put into the equation the benefits of direct-to-patient results.

    First the costs. When we send results to patients without requiring the physician to see them first, the patients get their info sooner. This translates into lower costs, because it reduces the patient-initiated calls, emails and visits to try to find out their results. The longer the delay, the more it costs the system.

    Second, we need to factor in the remarkably empowering experience of patients getting direct and unexpectedly timely access to their results. In the patient reactions I've seen and heard, this disintermediation isn't seen as taking the doctor out of the process–the doctor is still involved. Rather, it's experienced as pulling the patient closer.

  5. Hi Tim and Hope,

    Tim – thanks a ton for providing perspective, because you have a great one (from lots of experience)…

    And Hope, yes, I think doctors should talk about what they are worried about when they order tests; I don't see how this is harmful, please feel free to add detail based on your experience,

    Ted

  6. Hi, Tim and Ted. I found your comments very interesting. But I wonder if the costs matter has really been studied. Tim says, “This translates into lower costs, because it reduces the patient-initiated calls, emails and visits to try to find out their results. The longer the delay, the more it costs the system.”

    But might it not be the case that the patient would get the results in a timely fashion and then expect an immediate follow-up? Will medical office staff be ready vis-à-vis knowing what to do as far as scheduling appointments for if it the patient who is requesting that one be scheduled with the doctor lagging behind? Won’t there will a lot of inefficiency unless the report comes with specific instructions to the patient as to what to do regarding follow-up or do you both expect that the patient will receive the report and then patiently wait around to be asked to schedule an appointment once the doctor has read the report and has decided what to do?

    And thank you, Ted, for these comments, "And Hope, yes, I think doctors should talk about what they are worried about when they order tests; I don’t see how this is harmful…" I think that would be helpful especially with ALS which is so hard to diagnose. I have read that many tests are done before patients are clued in as to what may be the problem and so the diagnosis can come as a shock.

  7. I can see both sides of the issue here.

    Doctors want to get the results first so they can decide a course of action before the patient is informed of the issue. They also make more money if you come in for the results. Also it is better for a person to be there to talk to there doctor if they have bad results so the doctor can explain the situation to them which can help pervent someone from going insane with questions if it turns out they have a major medical issue.

    But I can see why it might be good for the patiet to get them first, so there isn't any uneeded delays or lost results. But if it was something serious and the doctor managed to not inform you properly of the issue wouldn't it be considered malpractice?

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