Systems form the basis of good risk management. The ProMutual Group advocates that every medical practice—whether office- or hospital-based—have a comprehensive risk management program that incorporates some or all of the following suggestions.
Annual exam not always enough
Even more frequent screening may be necessary if the patient has a specific breast complaint.
Every practice should have guidelines for these exams, including instructions on identifying women at risk because of personal or family history (ALGORITHM).
Ultrasound, MRI for young women
Younger, otherwise healthy women with unimpressive findings such as nodularities, nipple discharge, or tenderness deserve extra attention. The physician may want to consider additional diagnostic tests such as ultrasound or MRI for this group.
Never disregard a complaint
If a woman complains of discomfort or a self-detected mass, immediate evaluation is imperative. This includes pregnant patients; do not wait until after delivery to investigate an abnormality.
Use your own guidelines, but justify deviations from the norm
These may include earlier screening for women at risk, and need not match the recommendations of a nationally recognized group. However, in the event of a claim or suit, you will need to justify the reason for deviating from widely accepted guidelines.
Incorporate a systematic approach to diagnosis, treatment, referral (if required), and follow-up breast care.
Using an algorithm can help minimize error, confusion, and delays in care.
Assume cancer until it is ruled out
Consider diagnostic mammography and, when indicated, ultrasound imaging when the screening mammogram of a patient with a palpable mass is either negative or inconclusive.
A fine-needle aspiration or biopsy is a must to resolve indeterminate breast symptoms or inconclusive diagnostic breast imaging tests.
What not to say to patients
Do not assure the patient that a breast mass is benign until it is proven to be so.
Are you the “default PCP”? Screen for other cancers
When more than 1 physician is involved, someone needs to assume responsibility for the patient’s ongoing breast care. In a malpractice case, a doctor cannot simply claim that a routine mammogram or diagnostic test was deferred because it was assumed another physician would handle it.
In most cases, the patient’s primary care physician has the responsibility for her care.
ObGyn can be held to primary care physician standard. If the ObGyn is her only physician, the ObGyn may be held to a primary care standard—not only for breast and cervical cancer screening, but also for colorectal, skin, and other cancers.
Any physicians involved in a woman’s care should decide between them, as early in the process as possible, who will assume responsibility for ongoing care. According to the Agency for Healthcare Research and Quality,6-9 that physician oversees follow-up, monitoring, and tracking women with abnormal findings, including those for whom a biopsy is recommended.
The designation of responsibility and accountability should be documented in the medical record.
The radiology facility’s responsibility. The facility that performs the patient’s mammograms must share responsibility with the designated physician for follow-up, monitoring, and tracking abnormal test results. Each facility should have a system for tracking positive mammogram findings and, according to the Agency for Healthcare Research and Quality, “a process for correlating findings with biopsy results.” It also has the duty to communicate urgent or significant findings to physicians and, under certain circumstances, to the patient directly.
If more than 1 physician is involved, everyone should know who is responsible for coordinating the patient’s ongoing care. Good communication is especially critical when abnormal findings are involved and additional imaging or more invasive testing is needed.
Document, document, document
ProMutual Group’s studies repeatedly show that inadequate records—whether paper or electronic—substantially reduce the chance for a successful defense.
Dr. Zylstra reports no financial relationships relevant to this article. Ms. Greenwald and Ms. Mondor are employees of ProMutual Group, Boston.