This case involves an otherwise healthy 55-year-old male patient in New Mexico with a family history of prostate cancer on his paternal side who saw his primary care physician for a prostate cancer screening. The test was ordered but the results were never communicated to the patient. Because he never heard from the physician’s office, the patient assumed that the test had come back normal. The patient came back a year later for another screening and the results came back well above 4.0 ng/mL. It was later discovered that the patient’s original lab results were high enough to warrant a biopsy 12 months earlier. The physician’s office alleged that the results were never sent to their office. The patient’s health rapidly deteriorated and he was diagnosed with prostate cancer. The patient died within 19 months of receiving his diagnosis.
Question(s) For Expert Witness
- 1. What is the standard of care regarding documentation of lab orders ordered on a patient?
- 2. What is a doctor's duty to follow up on labs orders when they are not received?
- 3. What is the standard of care to report abnormal PSA results to patients?
- 4. What is the standard of care to advise a patient with an abnormal PSA on treatment options?
Expert Witness Response E-074812
Most primary care organizations now recommend against routine PSA testing. If a test is performed, it should only be after a discussion about potential harms and very few, if any, benefits. Abnormal test results of any kind should be communicated to a patient in a timely fashion. Any lab tests ordered that do not arrive in the office should be traced. Office procedures should be in place to ensure both occur. It is not an adequate defense to say that the lab test was not received in the office. I was an expert witness for a case in which the primary care doctor did not conduct PSA testing on a patient who was later diagnosed with prostate cancer. The problem for this doctor was that he ordered the PSA test in the first place and then did not act on the results. This error gave the appearance of having led to the patient’s advanced prostate cancer while in truth, screening was unlikely to have affected this outcome and should not have been done, to begin with.
Expert Witness Response E-026124
Any tests that are ordered during an office visit should be documented in the chart. Ideally, the physician’s office should have a process in place to follow up on labs that are not received. However, there are many reasons why a test might not be received including; the lab lost the specimen, the patient did not have the test done, or the patient had the test done with another provider. It is not within the standard of care to expect that the physician followup on every lab test that is not received by his or her office. An abnormal PSA should be reported directly to the patient. Reporting should be done verbally or. If this is not feasible, reporting should be conducted via certified mail or another method which documents that the patient actually received the result and appropriate followup instructions. Treatment options for an abnormal PSA include antibiotics and rechecking, checking serial PSAs (watchful waiting), prostate biopsy, and prostate MRI. There are additional options which can be discussed with a urologist. If the physician does not have sufficient expertise in these options, a referral to a urologist should be placed.