Canceling a Patient's Medical Procedure

I spend most of my time these days in the endoscopy suite.  Most of these patients are meeting me for the first time. The patients seem quite accepting that a perfect stranger will be performing their medical procedure.  This is one of the realities of practicing in an institution that manages an enormous volume of patients.  The patients assume that they have been linked with a competent practitioner.  This is analogous to a patient who is scheduling a chest x-ray or a CAT scan.  The patient has no idea or concern over which physician will be interpreting the films. They assume competence and no longer need an established rapport. 

What I will state next may seem bizarre to readers, but stay with me on this.  From time to time, I have difficulty ascertaining the reason that a patient has been sent for a scope examination.   More often than you might think, the patient is unclear why the test was scheduled.  “My doctor ordered it,” is a common refrain.  In these cases, I can usually determine the reason after a thorough scouring of  the record, but not always.  Sometimes, the scope was ordered months ago, or even longer, to evaluate a symptom that has since resolved. On occasion, despite our best efforts, neither my Sherlockian staff nor I can divine from the chart why the patient is before us.

My staff are medical record detectives!

1904 drawing of Sherlock Holmes

This is a frustrating situation.  It could be that the referring medical professional ordered the test for a good reason after a phone call with the patient that was not documented in the record. And it could be that the documentation is in the record but hidden in a dark crevice layers below what I review.  (I know this may sound ridiculous, but more than once, my able staff has found a medical record I have been searching for that was buried deep or simply misfiled or mislabeled.)

First, let me reassure readers.  In nearly every case, the system works well.  The  patients know the indications for the procedures and the medical records support the need for the exams. 

However, during the week prior to penning this post, a patient arrived scheduled for a scope exam of his esophagus and stomach.  He had no idea why he was in our office and the medical record was mute on the issue.  He had no symptoms.  I was unable to reach his physician.  So, we sent him home.

The patient understood our decision.  Should we simply have proceeded?  I don’t think so. First we need to know that the scope exam - which has some risk - makes sense and is supported by the record.  And, what if there was a scheduling error and he was supposed to undergo some other medical test elsewhere?  If I performed the scope exam under any of the above circumstances and a medical complication developed, how would I explain all of this to the patient and the family afterwards?

In the medical world, when there is doubt and uncertainty,  we should pause and reassess.  If I find myself uneasy about proceeding, then I strive to ease my mind to protect the patient.  At times, cancelling the case is the best option.  Primum non nocere - first, do no harm.

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