Curbside Consult with Dr. Jayne 11/7/22

There has been a lot of discussion recently about practices that send patient portal questionnaires for existing patients to enter their medical histories. Certainly as a patient, I don’t want to enter information that already exists in my chart, and as a physician, I don’t want to have to reconcile a bunch of information that might already exist in the chart against patient-provided information that may or may not be accurate. Some patients are great at knowing their histories, others are less so.

Once a year, I have an appointment at a major academic center’s high-risk breast cancer program. This year, I was pleasantly surprised that for the first time, they didn’t ask me to provide information that they already had in my chart. The check-in process was quite streamlined even though three separate appointments were involved, so I was looking forward to a smooth visit.

The visit itself was great, with speedy access to an exam room, an upgraded exam gown (flannel with satin trim, if you can imagine), and a short wait for the physician. From there I went to the imaging center waiting room. Although the technician was apparently looking for me in the wrong waiting room (they have three), they ended up locating me quickly enough to get me to my imaging appointment early.

My technician was personable and efficient, making me feel like a valued patient and not like just another patient in a long line of tasks for the day. From there it was back to a different waiting room, where I received preliminary imaging results and met with another physician.

After discussing the care plan, they mentioned that a final radiology reading would be available to me via patient portal within 24 hours. They also explained that due to their current patient mix, they were asking some patients to schedule with a midlevel provider rather than the physician for their next visits. Knowing what I know about healthcare economics and physician staffing, I understood what they were trying to do in making sure the physicians have capacity to manage the patients who need active management of breast cancer and who are planning surgeries in the near term. As a patient, you put a certain level of trust in a leading academic institution to have appropriate physician oversight when you’re seeing a midlevel provider, and as a physician, I know how to advocate for myself if the need arises.

The visit hit a glitch during the checkout process, since there was no one to staff the checkout desk and everyone was being sent to the waiting room. There was quite a line since most patients needed multiple follow-up appointments for imaging, biopsies, or additional clinical appointments. I had plenty of time to read the Patient Bill of Rights they had posted on the wall, which specified that patients might see a physician assistant or a nurse practitioner as part of their visit. It also spelled out that patients have the right to see the physician if they prefer, although that might result in the rescheduling of their appointment. It’s standard stuff, and I didn’t think too much of it until the patient in front of me began to check out.

She handed over her check-out instruction sheet and began asking questions about the providers listed on the board behind the receptionist, as well as their credentials. She was asking which were breast specialists and which were other types of surgeons since it’s a mixed office. The receptionist was describing them, and when she got to the nurse practitioner, she said “Oh, she does everything,” to which the patient responded asking, “Why didn’t she go to medical school then?”

My ears perked up at that and I knew it was going to get interesting. It’s not hard to overhear things when you’re literally three feet apart, and apparently the patient had been given the same information that I had about not seeing the physician at the next visit and wasn’t aligned with the plan. She was shopping for a different surgeon rather than see someone she stated had less education. Having just read the Patient Bill of Rights, I wondered how the office would handle it. The receptionist said she would go and check with the physician.

While she was gone, the patient — with whom I had exchanged pleasantries about my cute tote bag while we were both in the imaging waiting room — turned to me and mentioned that she knew what the answer would be since the doctor had already told her she had to see the nurse practitioner. She went on to say that she was a cancer survivor and that she is scared to not see her surgeon, who knows her the best. I nodded empathetically and waited to see what would happen.

The receptionist came back and announced that she had spoken to the physician and the answer was still no – she would need to schedule as directed. Clearly that didn’t align with the posted Patient Bill of Rights, and honestly if the organization isn’t going to follow it, they need to take a good look at either modifying it or removing it from the office while they reconsider.

I was able to get my follow-ups scheduled and headed home, eager to get my final reports and try not to think about the whole situation for another six months, which is sometimes the best way to approach it as a patient. I buried myself in work the rest of the day, waiting for the familiar notification from the patient portal app that my result was available.

Unfortunately, the notification didn’t come. Nor did it come the next day, or the next, or the following one. I was busy with work and didn’t have a chance to call and wanted to also give a little benefit of the doubt since I know healthcare is in crisis. But now we’re in the weekend, and I’m relegated to wondering where there is a backup in radiology, whether my study was missed, or whether I’m going to get a callback to come back for more images. I know the system’s EHR and how it’s configured to handle release of test results to patients. Once radiology images are final, they release to the patient. The question then becomes whether something is wrong with the EHR and portal systems, or with the test itself.

Since it’s the weekend, I guess I’ll sit and wonder for a few more days, which is never a position a patient wants to be in.

Thinking about the situation as a whole, I think the practice needs to do some introspection around its messaging. In addition to the Patient Bill of Rights issue, they need to provide additional instructions on what to do if imaging results don’t come back. I’m a physician and know to track it down when Monday comes, but a lot of patients might be from the “no news is good news” generations, or don’t have patient portal access, and wouldn’t know to follow up a missing result. In the mean time, I’m off to a conference, so I will rely on my calendar to remind me to make the call.

Does your organization’s patient summary give instructions on what to do when results don’t return? Do you honor your posted Patient Bill of Rights? Leave a comment or email me.

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