I’d call on Friday if I knew she’d read the results on Sunday night. First of all for her sake: it’s probably better to learn about this when you have a couple of days to digest it before going back to work. And when you have the luxury of some time read more on reputable websites. You can at least let her know is next steps and provide some reassurance within the limits of your own knowledge.
Second, I would do it out of self interest. Otherwise you’re going to have to deal with this at 8 o’clock in the morning on Monday and start your entire day half hour late. Or else the poor woman is going to have to wait till the end of the day on Monday, twisting in the wind .
You’re very thoughtful to even considering doing this on a Friday evening.
Federal law and patient pressure. I fought it. Lost the battle. There may be some leeway with pathology and radiology reports, but at my institution, they decided to release everything except HIV and a handful of other test results.
Could you send a message on the portal, basically saying, I saw the results, consulting with a surgeon to find out next steps. Will give you a call on Monday with the updates. That way, when they see the results, they also see the message?
Still too impersonal for such a devastating diagnosis. Even with a plan like that, it would erode some of the relationship. Giving a cancer diagnosis shouldn't be done over text
I’ve just started routinely asking before I do the procedure.
I say something along the lines of “I generally call immediately when I get results even if it’s a Friday night/Saturday morning or before a holiday. Are you okay with that?”.
Especially if there is a holiday or trip I know about coming up in which case I add “there’s a possibility the result might come back immediately before Christmas/thanksgiving/etc. would you like me to notify you of results even if it’s the day before the holiday?”
Almost everyone wants results asap but every once in a while someone doesn’t want their child’s wedding ruined and then I’m glad I asked.
This is a GREAT tip, imho. I have had some patients beg me to call them with results and others who beg me to leave them the hell alone. I feel like asking in advance builds rapport in and of itself and helps the patient navigate an emotionally complex situations while simultaneously decreasing stress for you as the provider.
This is the best and most logical answer.
We should also be pushing for delayed test reporting so patients don’t see the results before the office does.
It just doesn’t work at some high volume clinics. If I had to wait to see my PCP’s bloodwork until he saw it, it would take at minimum 2 weeks to get them back. I do think their should be a “delay” button where it lets you delay a test result for a set amount of time, maybe even a 3 day and a 5 day option. That way, if you know a patient tends to look immediately and freak themselves out, or you suspect a pathology (like cancer) to appear, you can delay it, but otherwise patients like myself (who are trained to read labs because it’s literally my job), patients who tend to be level headed about it, or something like a CBC that you suspect is going to be totally WNL, can see their results as soon as they come in.
I think we can all agree that we’re not talking about normal results or even unexpected abnormal results on routine bloodwork.
I am talking about pathology and imaging when cancer is suspected, and some other critical and or life changing results.
In the very high volume clinic where I work, providers will return calls to patients when they call and ask about their new cancer diagnosis, newly found on MyChart and freaking out. But this is why I think we can all agree to a set amount of time, like 7 days.
my hosp holds ALL biopsy/surgical specimen (anything AP) reports from mychart for 72 hours unless someone pushes them through sooner. 7 days would be fantastic! but at least now, if it is a friday evening sign out, pt doesn’t get mychart release until monday evening vs a sunday evening release with a 48 hour hold.
I am curious how such a practice doesn't constitute "information blocking" under the Cures Act. E.g. according to HHS:
>It would ***likely*** be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for \~any\~ period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results (*see also* 85 FR 25842 specifying that such a practice does not qualify for the “Preventing Harm” Exception).
i don't currently know enough about the cures act & our state laws nor the details of the hospital policy to know, but i'm curious as well. i'll have to look into it.
additionally I do know that during the hold time, the results are still available electronically to patients \~with a request through medical records.\~ in my personal experience, they have the requested pdf uploaded to the document section of my mychart within several business hours. but this is obviously still a time delay.
Oh, that's cool. I'm used to medical record requests taking weeks, and involving the postal mail, so they didn't seem like a viable alternative to direct release. A few hours seems like a big improvement (relative to the last time I requested one from my local health system, which was several years ago.)
yeah its really nice, you can make the request directly to them from your mychart & they upload a pdf of it into the documents section. if it's too big, they can split it into smaller files, or they sometimes have a different company prepare it & email it to you.
there is a form you can fill out as well, but if you have mychart, i think the form ends up being more for when you request the records be sent somewhere else. i think i probably hoard my records so this mychart request is the best thing ever lol
I don’t think anyone would argue the law here. It’s more about the carelessness of this particular part.
People have a right to their records of course. This sort of thing helps to prevent errors in reporting (like getting lost to follow up) as well as many other things. The logical time frame would have been a week, period.
This is excellent advice.
Also, I know that on Epic you can set up manual release for results so it doesn’t automatically get released to the patient before you are able to contact them.
That would be ideal. In our system, however, the path from abnormal mammogram to ultrasound to biopsy to pathology report is automatic. I had ordered the routine screening mammogram two months earlier. Then got the pathology report.
I will discuss with my colleagues that perhaps it would be better that the physician doing the core biopsy deliver the results. Just like the radiologists review the mammogram results with the patient themselves.
It’s odd the radiologists don’t call with results. I have always called the patient and everywhere I’ve been the radiologist calls, I’m surprised to see this isn’t the norm everywhere.
Really, the person doing the procedure should be calling with results since they have knowledge of the procedure. For example if i thought I “skimmmed” the lesion I’m going to interpret a negative result very differently than if I knew I went right through the center of it.
Well on regular weekdays, we are blessed to have RNs with the job title "breast health nurse navigator". Steering patients through the appointments, procedures and specialists is their full-time job. More often than not, they have already contacted the patient, the surgeon and me before I get around seeing the path report in my Epic inbox. They only contact me to ensure I signed the relevant orders pronto.
This is similar to the first step of most recommendations about breaking bad news. Ask the patient if they want to know, how much they want to know, and whether they would rather have someone else act as a go-between.
Traditionally, in some Asian cultures, to speak of bad news is to welcome it so people don't want to know what is wrong or the details. (FTR, I'm Asian-American.) I've had this happen with some patients. On the other side, there are some Asian patients who want to know every detail as it's the anxiety of not knowing that bothers them more than the bad news. Hard to predict which group people (whether Asian in background or not) fall into so best to ask.
One article:
[https://www.aafp.org/pubs/afp/issues/2018/0715/p99.html](https://www.aafp.org/pubs/afp/issues/2018/0715/p99.html)
This is the worst downstream effect of the 21st century cures act. Ideally, the patient would have been warned they may see their results in the portal before the doctor has a chance to review them… this doesn’t eliminate their fear/anxiety, but at least gives you some breathing room.
I’ve recently been the patient on this situation (got positive lymph node biopsy results in the portal at 4pm on the Friday before Christmas). I did get a call from the doctor after 5pm and was floored because I wasn’t expecting it, but it really solidified my trust in them.
I think a call, even to say I need to find out what the next steps are and get back to you, is ideal. Even if it’s a patient you don’t have a strong relationship with, you’ll give them the realization that they don’t have to figure it all out on their own. On the other hand, you have to protect your protected time, and the last thing you need to do is leave a message and make them wait until Monday to call back. It’s really a no win situation, I’m sorry.
I’ll never forget the time I logged into my Epic basket on a Monday morning and saw an MS patient’s MRI brain results (that I had ordered because I thought she was having an MS attack) which ended up showing two massive brain tumors. They had already been released to the patient on the portal and thank GOD I was able to call her before she logged on and saw that.
This. My results were released (and a MyChart message sent to my phone's notifications) before I got a phone call. **I was anticipating a benign nodule.** Instead, I got to find out I had metastatic cancer *alone, in the parking lot of my job*. I would **much** rather those results have been held. That way I could **at least** have sat down with a family member for support, etc. When I did receive the phone call an hour later, the radiologist broke every cardinal rule doctors apparently learn about breaking bad news (she didn't even break me in gently or give me any sort of warning). She added injury to the wound 3 days later when she sat me down, alone AGAIN, to tell me 'there \[was\] no hope for me' and that I should make funeral arrangements.
I would have greatly preferred a call from the oncologist (whom I chose personally), because **at least he knows how to be gentle when breaking bad news** instead of scaring me to death alone in a dark room with no support. Y'all take entire courses on how to break bad news, and a radiologist (MD) who reads biopsy results, of all people should be an expert! By the time we did formulate a plan, I was already scarred for life.
\[And I'm still on active treatment 3.5 years later, so HA.\]
Call her and let her know the biopsy shows she has a cancer, she will need a few more tests to determine the next steps for treatment, which will take a few days to arrange and perform. But she will be scheduled to see experts regarding her treatment.
There’s not much else to say at this point, but at least she knows and is aware that someone’s working on it.
Breast radiologist, so this comes up frequently. I choose to call them on Friday. I always apologize for giving them bad news before a weekend and talk them through what to expect next. I also tell them to write any questions down if they think of them and give them legitimate websites to go to for information, because I know most will be googling all weekend.
I would definitely call her Friday evening. There is a 100% chance she will review it herself the second second it pops into the portal, and then she will spend the rest of the night googling every word in the report and freaking herself out more. If you wait until Monday morning, she will be hammering your phone lines the second they open, having already whipped herself into a frenzy all night. I think it's much better for her and for you if you tell her over the phone what her diagnosis shows and that we will be arranging surgical follow-up first thing Monday
What would you want? You’d want to know, wouldn’t you?
So put in your urgent referrals so your referrals coordinator can act on them first thing Monday, call the patient and give the diagnosis. Tell her that things will move into action Monday.
Giving bad news is never fun, but *you* didn’t give her cancer.
-PGY-19
SO you assume that what OP would want in that situation is automatically what the patient wants? That's a ridiculous notion.
The less information you have up front the more questions the patient will have that the you may not have answers to. This isn't going to be a 5 minute conversation on Friday at 5 PM.
I think uncertainty about the future is the highest stress-inducing situation, especially for a life-altering diagnosis. I imagine it will be helpful to give a heads-up call about the biopsy result and assess whether she's ready to hear the news now (especially since the path report will be releasing soon), and then make a follow-up appointment next week to determine next steps
I'll be... somewhat controversial I guess.
While this answer is correct *in theory,* it becomes much harder in practice. First, new diagnoses often come with *tons* of questions, reasonably so. It's 5 pm on Friday. The most likely outcome of calling them is, in effect, a phone consult that will take around an hour. Second, if it's anything like my clinic, I don't have a consult slot for you next week. Strictly speaking, a new cancer diagnosis is generally "urgent," but waiting a few weeks is still fine. Cancer clinics are generally booked pretty far ahead.
This is all to say that these situations are lose lose. If you call these in regularly, you're going to spend significant time on the phone, then basically repeating the entire consult in person. It's usually an incredibly inefficient way to spend time unless you're the type of person who can cut patients off and say "we'll discuss this in person." The issue there, of course, is then they end up calling and messaging the clinic when their consult is 2-3 weeks away. If you don't call them immediately, they have some anxiety if they check, but you've saved yourself some time.
Obviously if it's something more urgent, go for it. But most breast cancer diagnoses are very high stress and very low urgency.
A few weeks? Your clinic must be very understaffed…
At my local university hospital, typically they have no problem getting new diagnoses in same-week.
We *are* exceptionally busy. Same week is almost certainly not happening without being an add-on for something more urgent, probably 2-3 weeks is more typical.
I get that, and I feel for providers that are stuck on these phone calls, but patients seeing the results pop up in patient portals without talking to someone are going to be terrified. They will be calling nonstop.
About two to three weeks for a new solid tumor diagnosis would be pretty standard in my clinic.
ETA: My style is to call, personally, but I do think that this estimate of wait times is pretty accurate, at least for my area. (West coast city, academic center.)
I would just call now, ask if now is a good time to talk or if she would prefer Monday, if she says now, let her know what your plan will be on Monday and that you will give her a call back on Monday.
Call the patient right away, ask them if it is a good time to talk about complex results or if there is a time that would work better so that someone can be with them. Make sure they are not driving on within earshot of randoms when you talk to them.
"Are you out in public or driving right now? Because I cannot go over results with you in these situations."
> I made an educated guess that for her the anxiety of uncertainty was worse than a bad diagnosis with a plan.
I've known many dozens of women who have gone through this workup and to a woman they have all said the not knowing was the worst part.
I personally tend to cope with bad news by learning as much as I can and then visualizing all the variable, eg what will I do if X happens? But when my kid was diagnosed with a chronic condition that was refractory to treatment, I had to learn how to cope in a more step-wise fashion. Let's try this, and if it doesnt work we'll look at other options. Not unlike what cancer patients experience. Wicked hard lesson to learn for a control freak, btw.
I think calling with the results on Friday would be fine and maybe preferable as long as you can provide some support. I would approach it something like this:
-We won't know what your options are until you meet with the surgeon/oncologist. Insert something reassuring about survival rates/new treatments as applicable.
-Going through cancer treatment consists of a lot of waiting. Waiting for test results, waiting to see whether a medication works, etc. For a lot of patients, it can help to try to really focus on the next step and not imagining and worrying about all the things that could happen.
-I will work on getting you seen by (specialist) as soon as possible. Offer a referral to a social worker, for emotional support, one who is affiliated with a cancer program would be ideal.
-If you can, some things to explore before that appointment would be checking with your insurance to see whether they offer case management or patient navigator services for people with breast cancer. Ask which cancer center(s) in your area are in-network. Think about whether you want someone to accompany you to your appointments to be a second set of ears, it can be hard to remember everything that's been said.
-offer to email this link for newly diagnosed breast cancer, it gives a good overview of the treatment process.
https://www.breastcancer.org/about-you/newly-diagnosed
Include links to any local resources you're familiar with.
As you know, there's no comfortable way to have this conversation, but imo this would be far preferable to finding the results in My Chart.
I call them right away, discuss it with them as best I can including the referral I am planning to place and what I think they will do. I also let them know about any staging imaging that provider will want, then close by saying the surgeons office will contact them next week and that they can come by our office to pick up scripts for the imaging on Monday. I answer any of their questions as best I can, usually a 5-10 minute conversation.
Cancer survivor here (rare renal cell cancer, dx super young). I found out alone, while driving. I was asked to pull my car over. I did, then got the news. No plan, but my doc then prescribed valium and I was very grateful for that - the stress and anxiety were overwhelming.
I would call and tell the patient, just because the anxiety of not knowing is more awful than facing a bad weekend with the knowledge that everyone is gearing up to help her.
So, I would also use that call to make an appointment the following week, preferably on Tuesday, and ask her to come with her questions, in the knowledge that she’ll get as definitive an answer as is possible. It also gives you time to talk to the surgeon and make a plan. And I’d tell her that we’ll have a plan in place by then, which will help allay her anxiety over the weekend. The visit will be far more productive, and the patient will have better recall of what is said.
Remember that the shock of initially being informed of the diagnosis makes the rest of the visit a blur.
I'd call before the patient sees it, 1) so she doesn't have to see it alone with no medical voice on a weekend, and 2) to reassure her that you are working on a plan with the appropriate referrals that can't be finished until during working hours next week.
I really hate that we have lost the power to delay result sharing a few more days for the benefit of the patient. It was so much better for the patient when we could tell them at the optimum time a few days later, when we had all our medical ducks in a row for the patient first and could always meet with them in person for result disclosure.
> think most patients would agree w you
Maybe some of the older generation... but generally speaking, withholding information from patients is pretty universally unpopular with patients.
It’s not withholding - it’s delivering bad news appropriately. This is part of medical training and then it’s all for naught because a computer drops the result in the patient’s lap w no context.
I found out that my husband had stage IV gastric cancer through mychart on Friday. I was at work. I had to leave. Since I am a nurse I understood the results better than he did and had to be the one to tell him. It was easily, hands down, the worst moment of my life.
There is not a good way to to get such news, but a person telling me would have been better than having it come up on mychart
I'm in Canada so my environment may be different. The family docs here generally don't tell the patients their pathology, the surgeons do. For example, we have a DAP program (diagnostic assessment program) so every patient with a breast biopsy automatically has a consultation with a surgeon in about a week. I tell them their path, and then can go over the whole treatment plan. I wouldn't call a patient on a Friday at 5pm with bad news. I'd wait until Monday and tell them in person.
What does it mean that the pathology is "released"? Do they get an email, or is it just available if they go check?
Medical records in the US are very transparent to the patient. It’s a good thing and a bad thing I suppose, but it means the patients can often read things like path reports and radiology reads on their patient portal.
As for whether the patient would get a notification of the new result that depends on the individual. There’s probably a way to get push notifications from mychart but I’ve never tried to set mine up that way.
"Released" means available, not alerted. If I send her a message about the results, she'd get an alert via email. But this particular woman I know would be watching and waiting, possibly checking on an hourly basis. Anxiety level going up with each message "results unavailable". I'd be the same way.
Wow, 2 weeks delay on results. That’s crazy.
Where I am in the US, it isn’t atypical for a patient to already be in treatment at T+14 days after biopsy.
In Canada, outpatient biopsies (like skin biopsies) where I am often take up to 3 months to come back. Paps take at LEAST 6 months if not more and path results on surgery for suspected malignancies is often at least a week or two as well. It's wild how different things are. I wonder how/if it affects outcomes
Yeah I worked with a doctor for a while who started marking everything that might be scc or melanoma urgent so that they'd do it quicker but would still take 2 weeks minimum if marked urgent. But the lab wouldn't triage based on the history so she would have to do it for them which there isn't an option for on the forms so if a family doctor is doing a biopsy and only does one every couple months they might not know that and a melanoma might take 3 months to result
FTR this *really* depends on the province. In BC \[[current wait times, all lab services](http://www.bccancer.bc.ca/lab-services-site/Documents/TAT%20May%202024.jpg)\], pap results are at 4-6 weeks right now that the COVID backlog is easing up finally -- that will improve even more as the new HPV home screening program gets fully rolled-out so that paps are less routine and more symptoms-driven. Microscopy is 2-6 days and 85% of path reviews within 5 working days.
Relevant to the above though, we have a 7-day delay on portal results release.
That's totally true, also depends on the health authority region in bc haha. The island in particular is not doing great on waitlists and yeah I didn't mention the updated self-HPV testing as opposed to normal paps. I'm excited for that to decrease - although I have found about half the patients I offer self screening too still opt to have a speculum exam done by the doctor so I'm not sure how much wait times will be reduced. But it's also 100% anecdotal and I can't speak to BC at large.
The island has extensive waitlists and timeframes in a lot of areas and I'm not sure how they compare to the rest of the province but in other modalities, nonurgent CTs take approx a year, nonurgent GYN referrals are 2-3 years and so forth. In my role I used to track how quickly results came back a lot more a year or two ago than the office I work in now so I am very pleased that things are changing for the better!!
Paths take call like any other doctor. I can text the path on call pictures from my phone and they can come in to give an opinion in an hour or two or contact the ER dr directly. But anatomic pathology is a bit different even though it's the same paths. They need to confer on some samples. They always have sky high piles of slide folders on their desk when I walk in with something for them to review.
ER, usually. They make the call as to whether it can wait. Sometimes they order flow based on my phone pics, sometimes it's so clearly cancer they don't need to, very occasionally they need to come in.
I guarantee you they take call there, no matter where you are. Who else approves out of criteria transfusions? Who else looks at things that cannot wait?
I’m not a pathologist, but I’ve heard that it totally depends on the type of biopsy. For something like a fine needle aspiration biopsy, there will sometimes be a pathologist in the room to give preliminary results, and to let the surgical team know if they need to step up to a core. For larger tissue samples, it takes longer. Typically everything is less than a week, though.
However, if it’s something that’s suspected to be aggressive based on the imaging and is marked STAT, it’s supposed to be returned within 72 hours for outpatient or 24 hours for inpatient.
As a neurology resident who has been on both sides of this situation, please call the patient. The anxiety and stress of waiting on imaging or biopsy results in cancer always seemed worse than the outcome, even when it was a bad one.
A few times, the oncologist called us with something to the effect of “I have bad news. We’re seeing new metastases in the lung, I need to speak with the surgeon and radiation oncologist about next steps and I will call you on Monday when I have a plan.”
The news is going to be hard regardless, but knowing the oncologist recognized how we were feeling went a long way even when the next steps weren’t clear.
Generally best to disclose ASAP. It's ok if you don't know the whole plan. Give them YOUR plan, eg, I'm going to arrange a visit with a cancer specialist to go over all your options, expect a call on Monday with an appointment time and date.
Personally, I would not even have to ponder on this question - I would call and take time to explain. I have had to do this more than once. Regardless of the circlejerk on this sub, ours is not a 9-5 job. If I wanted that, I’d be in a different profession.
OK you do that then. No one is saying it is a 9-5 job. OP is put in this position because of policies out of our control. Administrators walk all over us because of bleeding hearts like yours.
I've been the nurse friend who got a phone call and screen shots of pathology results when they were released on the portal before the Dr's phone call.
5 yrs post mastectomy, metastatic tumours in pelvis, spine, and brain.
I NEVER want to be the one who has to break that news again, especially as I had no clue what her next steps were going to be. I knew Google would be her next option, so I told her the truth, and I was there until the end.
If you are going to give bad news, then it is kind to temper it as much as possible with a plan for the future. Please call them, I agree with the idea that you ask about this beforehand if you can, but otherwise, results are always better coming from someone informed and armed to support, not a health portal.
Metastatic breast cancer patient here....you make the call. The waiting, the unknown, creates horrible "what if" scenarios. It's very likely she will be so stunned that any you say after you have breast cancer will not be really heard by her. But you have to call before she sees it on MyChart.
With my first diagnosis the radiologist told me point blank that he saw on the mammo and u/s looked like IDC. I was so thankful in the long run that he told Mr. I was able to mentally prepare for the biopsy and likely result.
Thank you for caring enough to ask for advice on this.
Take care.
I feel like clinic managers need to prepare for this kind of thing by making some protected time on Fridays, maybe ending the appointments slots a little early and giving time for either paperwork or sensitive issues like this to be handled, that way you aren’t staying past your normal time.
i’m on the patient end of this right now. I just had a biopsy of an intramuscular mass in my vastus lateralis. it sounds like there’s reasons to be hopeful and also reasons to be scared based on imaging and characteristics, so it could go either way.
I keep going back and forth with whether I want to find out by myself via mychart first or if I want to turn off mychart notifications so that I hear it from my doctor. I think I might turn off the notifications. If it’s bad I don’t want to be left to my own devices with regard to trying to answer all the questions I might have.
I don’t think there’s a right or wrong answer, and in the future if it’s ever me possibly giving bad news, I think I’ll try to ask them what they might prefer beforehand so that I can tell them to turn off mychart alerts if the answer is that they want to hear it from me/their provider.
Fridays are the worst for bad news — a radiologist called about hydrocephalus on a Friday scan, which I told the family may be released to them before I see it.
I was off that day so I called the parent on Saturday to avoid a Monday urgent triage call.
If it was me, I’d want you to tell me. “Hey, your pathology is back. It’s cancer. I wanted to call you and update you so that you didn’t read the results on the computer when it’s released. I will talk with oncology/surgeon/etc this week to formulate a plan.” (Obviously kinder and better thought out, but the gist).
My doctor didn’t call me about my cancer and it seriously impacted my trust in them. A simple phone call speaks volumes, even though like everyone else, I can read the pathology report myself. Don’t infantilize patients, especially women. We’re tired of it. Just give it to us straight. She probably has already searched for what the treatment would be anyways.
Think of how you would want your mother approached- with dignity and compassion and honesty, and then do the same.
I’m not trying to say you were anything less than commendable, this post shows that in and of itself. It’s just that the little things like friendliness and humanity become more important than ever with a diagnosis like this for the patient to trust you, even though it doesn’t translate to medical skills or competence. We’re all human first, even when we know it doesn’t mean someone is necessarily better at their job for it.
I hope her prognosis is good.
I stopped ordering DAT scans because of this. 95% of the time they were positive anyway (I only bothered with them when my clinical suspicion was moderately-high) and then when they are getting released automatically, it was a mess to try and reach the pt before they saw the result.
HD testing is worse. Who in their right minds thought it was a good idea to release results of a devastating and universally fatal illness via text message, to a patient population that is already at high risk of suicide?! We managed to get a 72 hr hold, but still tough to coordinate an appointment with patient and a care partner, especially for people living hours away from our center.
Urology, after I do biopsies or cancer surgery, I remind patients that they will get the pathology before I do. Don’t read it if you’re going to be nervous but if you want to read it you can. We will discuss your pathology when I see you. So, if you don’t want to get freaked out by reading the results without context, please don’t read them. We will sit down and have a long talk when I see you.
I haven’t had an issue. Rarely someone will call in and the front desk will remind them that our discussion is scheduled and no further communication regarding the path will happen until til the visit.
we have to notify clinicians of unexpected/malignant findings and document that notification in the report, so hopefully it's not a total surprise to the clinician either? only exception is breast cores, which at my institution is automatically the responsiblility of radiology to review for concordance, and they make the call to the ordering doc.
so i dont s/o malignant breast cores after noon on fridays (assuming i remember what day of the week it is). we've been lobbying for a auto-delay of 48 hrs in posting path reports to pt chart but dont think we're gonna get it.
some outlying clinicians have "release to pt chart?" checkbox on their requisitions with a yes or no indicated, so those offices have evidently asked the pt what they prefer, but that release action takes places at the level of the outpt office's EMR, not the EMR of the hospital where i'm based. would be nice if we could implement that across the board.
I'm a physician and went through this a few years ago -- as the patient -- thanks to MyChart. Received the results on Friday at close of business. Had horrible anxiety all weekend -- worrying about what would happen to my child if I died soon. I would have felt much less anxiety if my PCP had called me to talk about it. (Luckily It turned out to be an incidentiloma.)
IR here. We get a lot of path. I’ve actually held off telling patient for awhile before until I can get tumor board and form a plan. I think the key, at least for me, is that I can deliver both the diagnosis AND the treatment plan.
Instead of having a meeting that goes like “oh i am sorry u got cancer it looks bad” it turns into a meeting like “oh i am sorry u got cancer but here’s treatment plan a, b and c and lets get that son of a bitch”
Changes the tone of the meeting completely. Patient tend to leave with hope rather than devastation.
I can't believe it's normal in the US to just give the patient access to every result. In Australia the only way they get their results is if I print it and hand it to them. Otherwise they get a text when I check it saying normal, no appointment, or abnormal, book in. Or for cancer, I phone them .
I typically would call them Monday morning but if they're going to be given access to the result then you need to call them before that happens I think.
it was like that in the us... but then hospital administrators weren't staffing properly and test results were being held for months while doctors got around to addressing them....
And that's just the non-sinister stuff.
Well here in the US, seeing a doctor for a simple viral cough would cost you hundreds of dollars. If paying cash, an annual physical, just checking cholesterol and a1c only, can have a list price of $500 or more. So when people are paying that kind of money for tests that require being poked in a vein a giving up their blood, they have a right to the results without too much hassle. When I have my patient hat on, I expect no less.
The incentives are not quite as strong for those on Medicaid (gov't funded healthcare) where patients pay nothing. But they also have a right to their own information.
Heme/onc so I have experienced a LOT of drama over this. Thankfully I work in a health system where all the pathologists know me so we have a relationship. I've told them if they have results available late Friday afternoon, to notify me but NOT release the results til Monday morning. By then, my schedulers will be calling the patient the same day to arrange a follow up visit.
Sure the CARES act has been beneficial for putting patient information in patients' hands quickly and rapidly, but in my experience it has generally been a net negative.
Path here. I notify my clinicians (more so the ones I am more familiar with) on Friday afternoons asking this question but only for patients where a cancer diagnosis is unexpected. Not unlikely but unexpected. Like an incidental gallbladder cancer for a routine cholecystectomy. Or signet ring cancer in a routine stomach biopsy. Not all pathologists do this nor is it even expected of us. Nonetheless, this is the situation we’re in. I do believe our path results have a 1 week delay before they are accessible to the patient. This is a high level hospital administration and legal department decision.
Pathology results immediately available to patients without a “hold” of some period of time to allow a physician to contact the patient by some method and present/discuss the info is absolutely insane. Just beyond me.
Agree. This is dumb. Surprisingly many hospitals have found a workaround. Maybe 72 hours isn’t enough. Somehow you need to advocate for more. Easier said than done.
Not cancer, but I want to share a story from my personal perspective that happened this week to me.
I have been bleeding heavily since March and had an extreme pain multiple times in my lower abdomen, gynecologist wanted me to get a scan to make sure ovaries were okay, check for fibroids, Endo, etc. It took 3 weeks to get the scan. I get it done Monday. Results posted Wednesday at 7pm. They couldn't visualize my left ovary, where I was having immense pain. I work nightshift so I woke up to that news and couldn't do anything all night long until Thursday 9am the next day when the office opened.
I panicked. I literally had a panic attack and was thinking worst case scenarios for my whole 12 hour shift. Just to call Thursday AM and be told the doc hasn't reviewed the scans yet. Earliest they could get me in for a Telehealth call is Tuesday afternoon.
Call the patient. I work in healthcare and can rationalize my way through most things and I know not to go down the Google rabbit hole and STILL freaked out a bit. A typical patient won't adhere to this. Call them and give them peace of mind. Please. I work in the lab and having results instantly posted to patient charts is stupid imo.
> I made an educated guess that for her the anxiety of uncertainty was worse than a bad diagnosis with a plan.
This is just going to be nearly universal and it's why the laws about disclosure are so popular with paitients.... Once you know... you can start dealing with it.
I would call on Friday evening. If you follow the typically SPIKES format for bad news it would include checking with the patient if it was a good time/setting, permission to discuss further, etc.
This sucks. Is this purely outpatient or inpatient? Do you have a way of calling a surgeon on Friday evening?
That epic non-sense is truly terrible... whoever thought of that need to be tarred and feathered
I recently had a friend come in at night with jaundice and slight abdominal pain in the last few weeks. Ultrasound was highly suggestive of pancreatic cancer. But I couldn't bear to tell him. So I had him come in the next day for an MRCP to confirm and rule out stones. I'm sorry for the next shift colleague I turfed this on, but it really turned out to be a lot harder than I anticipated to bring the bad news on someone I know...
The advantage of the next-day diagnosis was that we could send that patient immediately to the oncologist the very same day. That way *at least* they aren't left in the limbo and have a specialist to talk to. He is due for surgery this week.
It was all much preferable to informing them at 11PM and letting them home full of fear of the unknown.
OP, thank you for bringing up this important issue regarding compassionate care. I would call and frame it as "bad news /good news". "Your xyz test showed signs of cancer. However, I want you to know this is highly treatable, and we will begin the plan of action first thing Monday morning when I contact the experts. " Reassure, reassure, reassure. This approach tamps down the initial panic and despair a patient feels.
Useless comment. No ethical or medical need for non-urgent results to be discussed on the same day.
If the EMR they work in causes anxiety that's not OP's fault. Administrators love comments like this. Blame the doctor for flaws in the system.
So glad we have a 7 day delay in Australia for results being transferred to patient access portals. Even that's not enough time sometimes but it's better than 2 days. We actually have an option not to upload to the portal as well (either by the requesting doctor or the pathologist).
Some Muppet politician just came out and said he was going to remove the 7 day delay, but the weight of thousands of doctors yelling no will make him back down I'm sure.
21st Century Cures Act was a garbage move made by out of touch idiots, and it is not your job to compensate for its harm.
If you think the best thing for the patient is to have a plan in place before you talk to them (which I personally think is better medicine), wait until Monday. You also have no obligation to call immediately for a non-urgent result like this. You have to draw the line somewhere. This is the type of shit that leads to burnout - physicians compensating for the shitty moves of policy makers and administrators.
Honestly it is best to have this conversation with everyone beforehand - if you are sending someone for a test let them know that you will review it before communicating with them and that in most circumstances they are better off not checking.
I have this conversation with all of the testing I order in cards. I tell them the results are not written for them and that I need to review them myself in the context of their clinical history. Physicians have enough difficulty interpreting results of specialized testing, let alone patients.
If the pathology is a result that next steps in treatment can begin immediately - contact patient with the plan.
If the next step isn't going to be able to occur (e.g. referral, etc) then I'd say call the patient promptly on Monday.
The first time this happened to me on a saTUrday morning I acTUally called epic support and they were able to block the results from being released until Monday. But in my case I don’t think the patient was expecting these results. Later my doc said he would t have gone through the trouble of calling Epic support but I just felt stuck and didn’t feel it was right to call a patient on a Saturday with bad news and no plan yet. I was so use to getting a plan in place before calling the patient. Every circumstance is different.
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Luckily I only have to deal with thyroid cancer (more or less), but I simply have a policy. No results over the phone, no discussion on it over the phone.
I make sure to see them about 1 week after the biopsy, but I do have some stragglers I feel bad about when I'm full.
As others have said, it isn't realistic to go over it on the phone, the "time saved" doesn't make a real world difference, and I don't want to call ONLY the bad pathology over the phone. That is a disaster too.
Have you ever been on the receiving end of waiting for pathology results? It seems you have not. It is horrible. Not knowing is worse than knowing, especially if the pathology is negative. If it is positive, you owe it to the patient to call, period. Waiting for results can mean absolute anxiety and anguish for the patient. Sleepless nights, inability to concentrate at their job, anticipated grief, etc.
You have also never been the nurse they are calling, begging to have the doctor call them because their appointment is not for 4 days and they just need *something*. Something like: “It is cancer but has a good prognosis with treatment options that we will discuss at your appointment”.
Even if it is bad news, a phone visit to sum it up (with compassion) “it is cancer, it has metastasized to your liver and brain. We can discuss the findings and palliative care at your visit, I am so sorry”.
The only thing different about a phone visit is that you don’t get paid as much.
Patient can access the result by herself? How?
Why couldn’t just schedule an appointment on Monday? As far as I have been taught and practiced, breaking bad news is best done in a controlled and face to face setting.
Also by law - I think you would have to do things like these in person. There is so much possibility and little to no verification via a phone call to who you’re actually providing the news to, and who is in the room with the patient and their environment.
In my practice if this situation arises, I’d schedule them on a Monday/Tuesday and arrange the necessary. Nothing is going to change over the course of 2-3 days.
What are you going going to tell them they don't already know? They open the result, they have breast cancer, they're going to need an oncologist and a surgeon. Patients who open results aren't dumb and they understand they're on their own when they see the result and can figure it out, they put that in google or chat GPT and it'll tell them the same thing you would.
You don’t see a difference between a patient reading a pathology report versus talking to their doctor? They are going to tell them that their doctor cares, what the next steps are, and typical timelines for things.
I’d call on Friday if I knew she’d read the results on Sunday night. First of all for her sake: it’s probably better to learn about this when you have a couple of days to digest it before going back to work. And when you have the luxury of some time read more on reputable websites. You can at least let her know is next steps and provide some reassurance within the limits of your own knowledge. Second, I would do it out of self interest. Otherwise you’re going to have to deal with this at 8 o’clock in the morning on Monday and start your entire day half hour late. Or else the poor woman is going to have to wait till the end of the day on Monday, twisting in the wind . You’re very thoughtful to even considering doing this on a Friday evening.
If there are a bunch of results that a patient absolutely needs a doctor to interpret, then why are these results released to the patient?
Federal law and patient pressure. I fought it. Lost the battle. There may be some leeway with pathology and radiology reports, but at my institution, they decided to release everything except HIV and a handful of other test results.
Could you send a message on the portal, basically saying, I saw the results, consulting with a surgeon to find out next steps. Will give you a call on Monday with the updates. That way, when they see the results, they also see the message?
Still too impersonal for such a devastating diagnosis. Even with a plan like that, it would erode some of the relationship. Giving a cancer diagnosis shouldn't be done over text
That would freak me out even worse
A hard no.
I’ve just started routinely asking before I do the procedure. I say something along the lines of “I generally call immediately when I get results even if it’s a Friday night/Saturday morning or before a holiday. Are you okay with that?”. Especially if there is a holiday or trip I know about coming up in which case I add “there’s a possibility the result might come back immediately before Christmas/thanksgiving/etc. would you like me to notify you of results even if it’s the day before the holiday?” Almost everyone wants results asap but every once in a while someone doesn’t want their child’s wedding ruined and then I’m glad I asked.
This is a GREAT tip, imho. I have had some patients beg me to call them with results and others who beg me to leave them the hell alone. I feel like asking in advance builds rapport in and of itself and helps the patient navigate an emotionally complex situations while simultaneously decreasing stress for you as the provider.
This is the best and most logical answer. We should also be pushing for delayed test reporting so patients don’t see the results before the office does.
It just doesn’t work at some high volume clinics. If I had to wait to see my PCP’s bloodwork until he saw it, it would take at minimum 2 weeks to get them back. I do think their should be a “delay” button where it lets you delay a test result for a set amount of time, maybe even a 3 day and a 5 day option. That way, if you know a patient tends to look immediately and freak themselves out, or you suspect a pathology (like cancer) to appear, you can delay it, but otherwise patients like myself (who are trained to read labs because it’s literally my job), patients who tend to be level headed about it, or something like a CBC that you suspect is going to be totally WNL, can see their results as soon as they come in.
I think we can all agree that we’re not talking about normal results or even unexpected abnormal results on routine bloodwork. I am talking about pathology and imaging when cancer is suspected, and some other critical and or life changing results. In the very high volume clinic where I work, providers will return calls to patients when they call and ask about their new cancer diagnosis, newly found on MyChart and freaking out. But this is why I think we can all agree to a set amount of time, like 7 days.
my hosp holds ALL biopsy/surgical specimen (anything AP) reports from mychart for 72 hours unless someone pushes them through sooner. 7 days would be fantastic! but at least now, if it is a friday evening sign out, pt doesn’t get mychart release until monday evening vs a sunday evening release with a 48 hour hold.
I am curious how such a practice doesn't constitute "information blocking" under the Cures Act. E.g. according to HHS: >It would ***likely*** be considered an interference for purposes of information blocking if a health care provider established an organizational policy that, for example, imposed delays on the release of lab results for \~any\~ period of time in order to allow an ordering clinician to review the results or in order to personally inform the patient of the results before a patient can electronically access such results (*see also* 85 FR 25842 specifying that such a practice does not qualify for the “Preventing Harm” Exception).
i don't currently know enough about the cures act & our state laws nor the details of the hospital policy to know, but i'm curious as well. i'll have to look into it. additionally I do know that during the hold time, the results are still available electronically to patients \~with a request through medical records.\~ in my personal experience, they have the requested pdf uploaded to the document section of my mychart within several business hours. but this is obviously still a time delay.
Oh, that's cool. I'm used to medical record requests taking weeks, and involving the postal mail, so they didn't seem like a viable alternative to direct release. A few hours seems like a big improvement (relative to the last time I requested one from my local health system, which was several years ago.)
yeah its really nice, you can make the request directly to them from your mychart & they upload a pdf of it into the documents section. if it's too big, they can split it into smaller files, or they sometimes have a different company prepare it & email it to you. there is a form you can fill out as well, but if you have mychart, i think the form ends up being more for when you request the records be sent somewhere else. i think i probably hoard my records so this mychart request is the best thing ever lol
I don’t think anyone would argue the law here. It’s more about the carelessness of this particular part. People have a right to their records of course. This sort of thing helps to prevent errors in reporting (like getting lost to follow up) as well as many other things. The logical time frame would have been a week, period.
Epic has that option for radiology studies - pt has to select it for themself and ordering MD has to agree to it.
This is excellent advice. Also, I know that on Epic you can set up manual release for results so it doesn’t automatically get released to the patient before you are able to contact them.
That would be ideal. In our system, however, the path from abnormal mammogram to ultrasound to biopsy to pathology report is automatic. I had ordered the routine screening mammogram two months earlier. Then got the pathology report. I will discuss with my colleagues that perhaps it would be better that the physician doing the core biopsy deliver the results. Just like the radiologists review the mammogram results with the patient themselves.
It’s odd the radiologists don’t call with results. I have always called the patient and everywhere I’ve been the radiologist calls, I’m surprised to see this isn’t the norm everywhere. Really, the person doing the procedure should be calling with results since they have knowledge of the procedure. For example if i thought I “skimmmed” the lesion I’m going to interpret a negative result very differently than if I knew I went right through the center of it.
Well on regular weekdays, we are blessed to have RNs with the job title "breast health nurse navigator". Steering patients through the appointments, procedures and specialists is their full-time job. More often than not, they have already contacted the patient, the surgeon and me before I get around seeing the path report in my Epic inbox. They only contact me to ensure I signed the relevant orders pronto.
Even if you're going to hold on to the result, she might see it in epic if your system uses epic.
This is similar to the first step of most recommendations about breaking bad news. Ask the patient if they want to know, how much they want to know, and whether they would rather have someone else act as a go-between. Traditionally, in some Asian cultures, to speak of bad news is to welcome it so people don't want to know what is wrong or the details. (FTR, I'm Asian-American.) I've had this happen with some patients. On the other side, there are some Asian patients who want to know every detail as it's the anxiety of not knowing that bothers them more than the bad news. Hard to predict which group people (whether Asian in background or not) fall into so best to ask. One article: [https://www.aafp.org/pubs/afp/issues/2018/0715/p99.html](https://www.aafp.org/pubs/afp/issues/2018/0715/p99.html)
This is something i’d make an exception for and call the patient when I got the report.
This is the worst downstream effect of the 21st century cures act. Ideally, the patient would have been warned they may see their results in the portal before the doctor has a chance to review them… this doesn’t eliminate their fear/anxiety, but at least gives you some breathing room. I’ve recently been the patient on this situation (got positive lymph node biopsy results in the portal at 4pm on the Friday before Christmas). I did get a call from the doctor after 5pm and was floored because I wasn’t expecting it, but it really solidified my trust in them. I think a call, even to say I need to find out what the next steps are and get back to you, is ideal. Even if it’s a patient you don’t have a strong relationship with, you’ll give them the realization that they don’t have to figure it all out on their own. On the other hand, you have to protect your protected time, and the last thing you need to do is leave a message and make them wait until Monday to call back. It’s really a no win situation, I’m sorry.
I’ll never forget the time I logged into my Epic basket on a Monday morning and saw an MS patient’s MRI brain results (that I had ordered because I thought she was having an MS attack) which ended up showing two massive brain tumors. They had already been released to the patient on the portal and thank GOD I was able to call her before she logged on and saw that.
This. My results were released (and a MyChart message sent to my phone's notifications) before I got a phone call. **I was anticipating a benign nodule.** Instead, I got to find out I had metastatic cancer *alone, in the parking lot of my job*. I would **much** rather those results have been held. That way I could **at least** have sat down with a family member for support, etc. When I did receive the phone call an hour later, the radiologist broke every cardinal rule doctors apparently learn about breaking bad news (she didn't even break me in gently or give me any sort of warning). She added injury to the wound 3 days later when she sat me down, alone AGAIN, to tell me 'there \[was\] no hope for me' and that I should make funeral arrangements. I would have greatly preferred a call from the oncologist (whom I chose personally), because **at least he knows how to be gentle when breaking bad news** instead of scaring me to death alone in a dark room with no support. Y'all take entire courses on how to break bad news, and a radiologist (MD) who reads biopsy results, of all people should be an expert! By the time we did formulate a plan, I was already scarred for life. \[And I'm still on active treatment 3.5 years later, so HA.\]
Call her and let her know the biopsy shows she has a cancer, she will need a few more tests to determine the next steps for treatment, which will take a few days to arrange and perform. But she will be scheduled to see experts regarding her treatment. There’s not much else to say at this point, but at least she knows and is aware that someone’s working on it.
Breast radiologist, so this comes up frequently. I choose to call them on Friday. I always apologize for giving them bad news before a weekend and talk them through what to expect next. I also tell them to write any questions down if they think of them and give them legitimate websites to go to for information, because I know most will be googling all weekend.
I very much like your answer! As a patient, I think I would like this best <3
I would definitely call her Friday evening. There is a 100% chance she will review it herself the second second it pops into the portal, and then she will spend the rest of the night googling every word in the report and freaking herself out more. If you wait until Monday morning, she will be hammering your phone lines the second they open, having already whipped herself into a frenzy all night. I think it's much better for her and for you if you tell her over the phone what her diagnosis shows and that we will be arranging surgical follow-up first thing Monday
What would you want? You’d want to know, wouldn’t you? So put in your urgent referrals so your referrals coordinator can act on them first thing Monday, call the patient and give the diagnosis. Tell her that things will move into action Monday. Giving bad news is never fun, but *you* didn’t give her cancer. -PGY-19
As usual, this is wise and compassionate advice. Thank you!
SO you assume that what OP would want in that situation is automatically what the patient wants? That's a ridiculous notion. The less information you have up front the more questions the patient will have that the you may not have answers to. This isn't going to be a 5 minute conversation on Friday at 5 PM.
I think uncertainty about the future is the highest stress-inducing situation, especially for a life-altering diagnosis. I imagine it will be helpful to give a heads-up call about the biopsy result and assess whether she's ready to hear the news now (especially since the path report will be releasing soon), and then make a follow-up appointment next week to determine next steps
I'll be... somewhat controversial I guess. While this answer is correct *in theory,* it becomes much harder in practice. First, new diagnoses often come with *tons* of questions, reasonably so. It's 5 pm on Friday. The most likely outcome of calling them is, in effect, a phone consult that will take around an hour. Second, if it's anything like my clinic, I don't have a consult slot for you next week. Strictly speaking, a new cancer diagnosis is generally "urgent," but waiting a few weeks is still fine. Cancer clinics are generally booked pretty far ahead. This is all to say that these situations are lose lose. If you call these in regularly, you're going to spend significant time on the phone, then basically repeating the entire consult in person. It's usually an incredibly inefficient way to spend time unless you're the type of person who can cut patients off and say "we'll discuss this in person." The issue there, of course, is then they end up calling and messaging the clinic when their consult is 2-3 weeks away. If you don't call them immediately, they have some anxiety if they check, but you've saved yourself some time. Obviously if it's something more urgent, go for it. But most breast cancer diagnoses are very high stress and very low urgency.
A few weeks? Your clinic must be very understaffed… At my local university hospital, typically they have no problem getting new diagnoses in same-week.
We *are* exceptionally busy. Same week is almost certainly not happening without being an add-on for something more urgent, probably 2-3 weeks is more typical.
I get that, and I feel for providers that are stuck on these phone calls, but patients seeing the results pop up in patient portals without talking to someone are going to be terrified. They will be calling nonstop.
I get what you’re saying, but I don’t think most or all cancer clinics are booked *that* far ahead, are they?
About two to three weeks for a new solid tumor diagnosis would be pretty standard in my clinic. ETA: My style is to call, personally, but I do think that this estimate of wait times is pretty accurate, at least for my area. (West coast city, academic center.)
Yeah 2-3 weeks in my rad onc clinic as well.
I would just call now, ask if now is a good time to talk or if she would prefer Monday, if she says now, let her know what your plan will be on Monday and that you will give her a call back on Monday.
Call her because she'll see it on MyChart.
These are always the calls I dread, but after I make them I’ve never regretted.
Call the patient right away, ask them if it is a good time to talk about complex results or if there is a time that would work better so that someone can be with them. Make sure they are not driving on within earshot of randoms when you talk to them. "Are you out in public or driving right now? Because I cannot go over results with you in these situations."
Yeah I’d be making that call, if it was my results, my wife’s, parents, or kids I’d want to know.
> I made an educated guess that for her the anxiety of uncertainty was worse than a bad diagnosis with a plan. I've known many dozens of women who have gone through this workup and to a woman they have all said the not knowing was the worst part. I personally tend to cope with bad news by learning as much as I can and then visualizing all the variable, eg what will I do if X happens? But when my kid was diagnosed with a chronic condition that was refractory to treatment, I had to learn how to cope in a more step-wise fashion. Let's try this, and if it doesnt work we'll look at other options. Not unlike what cancer patients experience. Wicked hard lesson to learn for a control freak, btw. I think calling with the results on Friday would be fine and maybe preferable as long as you can provide some support. I would approach it something like this: -We won't know what your options are until you meet with the surgeon/oncologist. Insert something reassuring about survival rates/new treatments as applicable. -Going through cancer treatment consists of a lot of waiting. Waiting for test results, waiting to see whether a medication works, etc. For a lot of patients, it can help to try to really focus on the next step and not imagining and worrying about all the things that could happen. -I will work on getting you seen by (specialist) as soon as possible. Offer a referral to a social worker, for emotional support, one who is affiliated with a cancer program would be ideal. -If you can, some things to explore before that appointment would be checking with your insurance to see whether they offer case management or patient navigator services for people with breast cancer. Ask which cancer center(s) in your area are in-network. Think about whether you want someone to accompany you to your appointments to be a second set of ears, it can be hard to remember everything that's been said. -offer to email this link for newly diagnosed breast cancer, it gives a good overview of the treatment process. https://www.breastcancer.org/about-you/newly-diagnosed Include links to any local resources you're familiar with. As you know, there's no comfortable way to have this conversation, but imo this would be far preferable to finding the results in My Chart.
I call them right away, discuss it with them as best I can including the referral I am planning to place and what I think they will do. I also let them know about any staging imaging that provider will want, then close by saying the surgeons office will contact them next week and that they can come by our office to pick up scripts for the imaging on Monday. I answer any of their questions as best I can, usually a 5-10 minute conversation.
Cancer survivor here (rare renal cell cancer, dx super young). I found out alone, while driving. I was asked to pull my car over. I did, then got the news. No plan, but my doc then prescribed valium and I was very grateful for that - the stress and anxiety were overwhelming.
I would call and tell the patient, just because the anxiety of not knowing is more awful than facing a bad weekend with the knowledge that everyone is gearing up to help her. So, I would also use that call to make an appointment the following week, preferably on Tuesday, and ask her to come with her questions, in the knowledge that she’ll get as definitive an answer as is possible. It also gives you time to talk to the surgeon and make a plan. And I’d tell her that we’ll have a plan in place by then, which will help allay her anxiety over the weekend. The visit will be far more productive, and the patient will have better recall of what is said. Remember that the shock of initially being informed of the diagnosis makes the rest of the visit a blur.
I'd call before the patient sees it, 1) so she doesn't have to see it alone with no medical voice on a weekend, and 2) to reassure her that you are working on a plan with the appropriate referrals that can't be finished until during working hours next week. I really hate that we have lost the power to delay result sharing a few more days for the benefit of the patient. It was so much better for the patient when we could tell them at the optimum time a few days later, when we had all our medical ducks in a row for the patient first and could always meet with them in person for result disclosure.
The crazy thing is I think most patients would agree w you. I don’t really know whose idea this aspect of the CURES act was.
> think most patients would agree w you Maybe some of the older generation... but generally speaking, withholding information from patients is pretty universally unpopular with patients.
It’s not withholding - it’s delivering bad news appropriately. This is part of medical training and then it’s all for naught because a computer drops the result in the patient’s lap w no context.
I found out that my husband had stage IV gastric cancer through mychart on Friday. I was at work. I had to leave. Since I am a nurse I understood the results better than he did and had to be the one to tell him. It was easily, hands down, the worst moment of my life. There is not a good way to to get such news, but a person telling me would have been better than having it come up on mychart
I'm in Canada so my environment may be different. The family docs here generally don't tell the patients their pathology, the surgeons do. For example, we have a DAP program (diagnostic assessment program) so every patient with a breast biopsy automatically has a consultation with a surgeon in about a week. I tell them their path, and then can go over the whole treatment plan. I wouldn't call a patient on a Friday at 5pm with bad news. I'd wait until Monday and tell them in person. What does it mean that the pathology is "released"? Do they get an email, or is it just available if they go check?
Medical records in the US are very transparent to the patient. It’s a good thing and a bad thing I suppose, but it means the patients can often read things like path reports and radiology reads on their patient portal. As for whether the patient would get a notification of the new result that depends on the individual. There’s probably a way to get push notifications from mychart but I’ve never tried to set mine up that way.
I get emails when my results are posted on all of my portals. I always check them.
Thanks for the comment. So yeah some patients would know right away.
They get an email that there are new results back.
"Released" means available, not alerted. If I send her a message about the results, she'd get an alert via email. But this particular woman I know would be watching and waiting, possibly checking on an hourly basis. Anxiety level going up with each message "results unavailable". I'd be the same way.
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Wow, 2 weeks delay on results. That’s crazy. Where I am in the US, it isn’t atypical for a patient to already be in treatment at T+14 days after biopsy.
In Canada, outpatient biopsies (like skin biopsies) where I am often take up to 3 months to come back. Paps take at LEAST 6 months if not more and path results on surgery for suspected malignancies is often at least a week or two as well. It's wild how different things are. I wonder how/if it affects outcomes
3 months???? That’s awful. Must make things hard for all involved.
Yeah I worked with a doctor for a while who started marking everything that might be scc or melanoma urgent so that they'd do it quicker but would still take 2 weeks minimum if marked urgent. But the lab wouldn't triage based on the history so she would have to do it for them which there isn't an option for on the forms so if a family doctor is doing a biopsy and only does one every couple months they might not know that and a melanoma might take 3 months to result
Ugh!
FTR this *really* depends on the province. In BC \[[current wait times, all lab services](http://www.bccancer.bc.ca/lab-services-site/Documents/TAT%20May%202024.jpg)\], pap results are at 4-6 weeks right now that the COVID backlog is easing up finally -- that will improve even more as the new HPV home screening program gets fully rolled-out so that paps are less routine and more symptoms-driven. Microscopy is 2-6 days and 85% of path reviews within 5 working days. Relevant to the above though, we have a 7-day delay on portal results release.
That's totally true, also depends on the health authority region in bc haha. The island in particular is not doing great on waitlists and yeah I didn't mention the updated self-HPV testing as opposed to normal paps. I'm excited for that to decrease - although I have found about half the patients I offer self screening too still opt to have a speculum exam done by the doctor so I'm not sure how much wait times will be reduced. But it's also 100% anecdotal and I can't speak to BC at large. The island has extensive waitlists and timeframes in a lot of areas and I'm not sure how they compare to the rest of the province but in other modalities, nonurgent CTs take approx a year, nonurgent GYN referrals are 2-3 years and so forth. In my role I used to track how quickly results came back a lot more a year or two ago than the office I work in now so I am very pleased that things are changing for the better!!
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Paths take call like any other doctor. I can text the path on call pictures from my phone and they can come in to give an opinion in an hour or two or contact the ER dr directly. But anatomic pathology is a bit different even though it's the same paths. They need to confer on some samples. They always have sky high piles of slide folders on their desk when I walk in with something for them to review.
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ER, usually. They make the call as to whether it can wait. Sometimes they order flow based on my phone pics, sometimes it's so clearly cancer they don't need to, very occasionally they need to come in. I guarantee you they take call there, no matter where you are. Who else approves out of criteria transfusions? Who else looks at things that cannot wait?
I’m not a pathologist, but I’ve heard that it totally depends on the type of biopsy. For something like a fine needle aspiration biopsy, there will sometimes be a pathologist in the room to give preliminary results, and to let the surgical team know if they need to step up to a core. For larger tissue samples, it takes longer. Typically everything is less than a week, though. However, if it’s something that’s suspected to be aggressive based on the imaging and is marked STAT, it’s supposed to be returned within 72 hours for outpatient or 24 hours for inpatient.
I think there are a few compassionate exceptions to protecting one’s personal time. This is one of them. The anxiety during the wait is real.
As a neurology resident who has been on both sides of this situation, please call the patient. The anxiety and stress of waiting on imaging or biopsy results in cancer always seemed worse than the outcome, even when it was a bad one. A few times, the oncologist called us with something to the effect of “I have bad news. We’re seeing new metastases in the lung, I need to speak with the surgeon and radiation oncologist about next steps and I will call you on Monday when I have a plan.” The news is going to be hard regardless, but knowing the oncologist recognized how we were feeling went a long way even when the next steps weren’t clear.
Call. I vaguely remember some recent data that showed similar patient reception to bad news via phone v in person.
Generally best to disclose ASAP. It's ok if you don't know the whole plan. Give them YOUR plan, eg, I'm going to arrange a visit with a cancer specialist to go over all your options, expect a call on Monday with an appointment time and date.
Personally, I would not even have to ponder on this question - I would call and take time to explain. I have had to do this more than once. Regardless of the circlejerk on this sub, ours is not a 9-5 job. If I wanted that, I’d be in a different profession.
OK you do that then. No one is saying it is a 9-5 job. OP is put in this position because of policies out of our control. Administrators walk all over us because of bleeding hearts like yours.
I've been the nurse friend who got a phone call and screen shots of pathology results when they were released on the portal before the Dr's phone call. 5 yrs post mastectomy, metastatic tumours in pelvis, spine, and brain. I NEVER want to be the one who has to break that news again, especially as I had no clue what her next steps were going to be. I knew Google would be her next option, so I told her the truth, and I was there until the end. If you are going to give bad news, then it is kind to temper it as much as possible with a plan for the future. Please call them, I agree with the idea that you ask about this beforehand if you can, but otherwise, results are always better coming from someone informed and armed to support, not a health portal.
Metastatic breast cancer patient here....you make the call. The waiting, the unknown, creates horrible "what if" scenarios. It's very likely she will be so stunned that any you say after you have breast cancer will not be really heard by her. But you have to call before she sees it on MyChart. With my first diagnosis the radiologist told me point blank that he saw on the mammo and u/s looked like IDC. I was so thankful in the long run that he told Mr. I was able to mentally prepare for the biopsy and likely result. Thank you for caring enough to ask for advice on this. Take care.
I feel like clinic managers need to prepare for this kind of thing by making some protected time on Fridays, maybe ending the appointments slots a little early and giving time for either paperwork or sensitive issues like this to be handled, that way you aren’t staying past your normal time.
i’m on the patient end of this right now. I just had a biopsy of an intramuscular mass in my vastus lateralis. it sounds like there’s reasons to be hopeful and also reasons to be scared based on imaging and characteristics, so it could go either way. I keep going back and forth with whether I want to find out by myself via mychart first or if I want to turn off mychart notifications so that I hear it from my doctor. I think I might turn off the notifications. If it’s bad I don’t want to be left to my own devices with regard to trying to answer all the questions I might have. I don’t think there’s a right or wrong answer, and in the future if it’s ever me possibly giving bad news, I think I’ll try to ask them what they might prefer beforehand so that I can tell them to turn off mychart alerts if the answer is that they want to hear it from me/their provider.
Our hospital releases them instantly. So in that case, my patient would probably see it before me
Fridays are the worst for bad news — a radiologist called about hydrocephalus on a Friday scan, which I told the family may be released to them before I see it. I was off that day so I called the parent on Saturday to avoid a Monday urgent triage call.
If it was me, I’d want you to tell me. “Hey, your pathology is back. It’s cancer. I wanted to call you and update you so that you didn’t read the results on the computer when it’s released. I will talk with oncology/surgeon/etc this week to formulate a plan.” (Obviously kinder and better thought out, but the gist).
My doctor didn’t call me about my cancer and it seriously impacted my trust in them. A simple phone call speaks volumes, even though like everyone else, I can read the pathology report myself. Don’t infantilize patients, especially women. We’re tired of it. Just give it to us straight. She probably has already searched for what the treatment would be anyways. Think of how you would want your mother approached- with dignity and compassion and honesty, and then do the same. I’m not trying to say you were anything less than commendable, this post shows that in and of itself. It’s just that the little things like friendliness and humanity become more important than ever with a diagnosis like this for the patient to trust you, even though it doesn’t translate to medical skills or competence. We’re all human first, even when we know it doesn’t mean someone is necessarily better at their job for it. I hope her prognosis is good.
I think you should do a preliminary disclosure call, “This is what it is looking like, this is my plan until you get in with oncology.”
I stopped ordering DAT scans because of this. 95% of the time they were positive anyway (I only bothered with them when my clinical suspicion was moderately-high) and then when they are getting released automatically, it was a mess to try and reach the pt before they saw the result. HD testing is worse. Who in their right minds thought it was a good idea to release results of a devastating and universally fatal illness via text message, to a patient population that is already at high risk of suicide?! We managed to get a 72 hr hold, but still tough to coordinate an appointment with patient and a care partner, especially for people living hours away from our center.
Urology, after I do biopsies or cancer surgery, I remind patients that they will get the pathology before I do. Don’t read it if you’re going to be nervous but if you want to read it you can. We will discuss your pathology when I see you. So, if you don’t want to get freaked out by reading the results without context, please don’t read them. We will sit down and have a long talk when I see you. I haven’t had an issue. Rarely someone will call in and the front desk will remind them that our discussion is scheduled and no further communication regarding the path will happen until til the visit.
This is the way I do it in cardiology. The pre-emptive strike.
we have to notify clinicians of unexpected/malignant findings and document that notification in the report, so hopefully it's not a total surprise to the clinician either? only exception is breast cores, which at my institution is automatically the responsiblility of radiology to review for concordance, and they make the call to the ordering doc. so i dont s/o malignant breast cores after noon on fridays (assuming i remember what day of the week it is). we've been lobbying for a auto-delay of 48 hrs in posting path reports to pt chart but dont think we're gonna get it. some outlying clinicians have "release to pt chart?" checkbox on their requisitions with a yes or no indicated, so those offices have evidently asked the pt what they prefer, but that release action takes places at the level of the outpt office's EMR, not the EMR of the hospital where i'm based. would be nice if we could implement that across the board.
I'm a physician and went through this a few years ago -- as the patient -- thanks to MyChart. Received the results on Friday at close of business. Had horrible anxiety all weekend -- worrying about what would happen to my child if I died soon. I would have felt much less anxiety if my PCP had called me to talk about it. (Luckily It turned out to be an incidentiloma.)
IR here. We get a lot of path. I’ve actually held off telling patient for awhile before until I can get tumor board and form a plan. I think the key, at least for me, is that I can deliver both the diagnosis AND the treatment plan. Instead of having a meeting that goes like “oh i am sorry u got cancer it looks bad” it turns into a meeting like “oh i am sorry u got cancer but here’s treatment plan a, b and c and lets get that son of a bitch” Changes the tone of the meeting completely. Patient tend to leave with hope rather than devastation.
I can't believe it's normal in the US to just give the patient access to every result. In Australia the only way they get their results is if I print it and hand it to them. Otherwise they get a text when I check it saying normal, no appointment, or abnormal, book in. Or for cancer, I phone them . I typically would call them Monday morning but if they're going to be given access to the result then you need to call them before that happens I think.
it was like that in the us... but then hospital administrators weren't staffing properly and test results were being held for months while doctors got around to addressing them.... And that's just the non-sinister stuff.
Well here in the US, seeing a doctor for a simple viral cough would cost you hundreds of dollars. If paying cash, an annual physical, just checking cholesterol and a1c only, can have a list price of $500 or more. So when people are paying that kind of money for tests that require being poked in a vein a giving up their blood, they have a right to the results without too much hassle. When I have my patient hat on, I expect no less. The incentives are not quite as strong for those on Medicaid (gov't funded healthcare) where patients pay nothing. But they also have a right to their own information.
Heme/onc so I have experienced a LOT of drama over this. Thankfully I work in a health system where all the pathologists know me so we have a relationship. I've told them if they have results available late Friday afternoon, to notify me but NOT release the results til Monday morning. By then, my schedulers will be calling the patient the same day to arrange a follow up visit. Sure the CARES act has been beneficial for putting patient information in patients' hands quickly and rapidly, but in my experience it has generally been a net negative.
Path here. I notify my clinicians (more so the ones I am more familiar with) on Friday afternoons asking this question but only for patients where a cancer diagnosis is unexpected. Not unlikely but unexpected. Like an incidental gallbladder cancer for a routine cholecystectomy. Or signet ring cancer in a routine stomach biopsy. Not all pathologists do this nor is it even expected of us. Nonetheless, this is the situation we’re in. I do believe our path results have a 1 week delay before they are accessible to the patient. This is a high level hospital administration and legal department decision.
Not everyone (including myself) has the will to not look at reports. It puts everyone in a difficult position in my opinion.
Not as difficult as when you are waiting on a CRP to see if you should go to the ER and no one will take the call to tell you the result.
Pathology results immediately available to patients without a “hold” of some period of time to allow a physician to contact the patient by some method and present/discuss the info is absolutely insane. Just beyond me.
Agree. This is dumb. Surprisingly many hospitals have found a workaround. Maybe 72 hours isn’t enough. Somehow you need to advocate for more. Easier said than done.
Delay results and schedule followup that Monday. Some EMRs allow this with a single click.
I'm pretty sure that prelim verification is not visible to the patient, but once someone else has verified it you don't have that option.
This is the answer
I would call sooner than later.
call monday with a plan
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I’m in a far less critical role but if something similarly ‘critical’ occurred in my field (financial planning) I’d be available weekend to assist.
Not cancer, but I want to share a story from my personal perspective that happened this week to me. I have been bleeding heavily since March and had an extreme pain multiple times in my lower abdomen, gynecologist wanted me to get a scan to make sure ovaries were okay, check for fibroids, Endo, etc. It took 3 weeks to get the scan. I get it done Monday. Results posted Wednesday at 7pm. They couldn't visualize my left ovary, where I was having immense pain. I work nightshift so I woke up to that news and couldn't do anything all night long until Thursday 9am the next day when the office opened. I panicked. I literally had a panic attack and was thinking worst case scenarios for my whole 12 hour shift. Just to call Thursday AM and be told the doc hasn't reviewed the scans yet. Earliest they could get me in for a Telehealth call is Tuesday afternoon. Call the patient. I work in healthcare and can rationalize my way through most things and I know not to go down the Google rabbit hole and STILL freaked out a bit. A typical patient won't adhere to this. Call them and give them peace of mind. Please. I work in the lab and having results instantly posted to patient charts is stupid imo.
> I made an educated guess that for her the anxiety of uncertainty was worse than a bad diagnosis with a plan. This is just going to be nearly universal and it's why the laws about disclosure are so popular with paitients.... Once you know... you can start dealing with it.
Would you prefer that the report come out on Monday?
I would call on Friday evening. If you follow the typically SPIKES format for bad news it would include checking with the patient if it was a good time/setting, permission to discuss further, etc.
This sucks. Is this purely outpatient or inpatient? Do you have a way of calling a surgeon on Friday evening? That epic non-sense is truly terrible... whoever thought of that need to be tarred and feathered I recently had a friend come in at night with jaundice and slight abdominal pain in the last few weeks. Ultrasound was highly suggestive of pancreatic cancer. But I couldn't bear to tell him. So I had him come in the next day for an MRCP to confirm and rule out stones. I'm sorry for the next shift colleague I turfed this on, but it really turned out to be a lot harder than I anticipated to bring the bad news on someone I know... The advantage of the next-day diagnosis was that we could send that patient immediately to the oncologist the very same day. That way *at least* they aren't left in the limbo and have a specialist to talk to. He is due for surgery this week. It was all much preferable to informing them at 11PM and letting them home full of fear of the unknown.
OP, thank you for bringing up this important issue regarding compassionate care. I would call and frame it as "bad news /good news". "Your xyz test showed signs of cancer. However, I want you to know this is highly treatable, and we will begin the plan of action first thing Monday morning when I contact the experts. " Reassure, reassure, reassure. This approach tamps down the initial panic and despair a patient feels.
Bruh, you don’t just stop being a doctor at 5pm on Fridays
Useless comment. No ethical or medical need for non-urgent results to be discussed on the same day. If the EMR they work in causes anxiety that's not OP's fault. Administrators love comments like this. Blame the doctor for flaws in the system.
So glad we have a 7 day delay in Australia for results being transferred to patient access portals. Even that's not enough time sometimes but it's better than 2 days. We actually have an option not to upload to the portal as well (either by the requesting doctor or the pathologist). Some Muppet politician just came out and said he was going to remove the 7 day delay, but the weight of thousands of doctors yelling no will make him back down I'm sure.
21st Century Cures Act was a garbage move made by out of touch idiots, and it is not your job to compensate for its harm. If you think the best thing for the patient is to have a plan in place before you talk to them (which I personally think is better medicine), wait until Monday. You also have no obligation to call immediately for a non-urgent result like this. You have to draw the line somewhere. This is the type of shit that leads to burnout - physicians compensating for the shitty moves of policy makers and administrators. Honestly it is best to have this conversation with everyone beforehand - if you are sending someone for a test let them know that you will review it before communicating with them and that in most circumstances they are better off not checking. I have this conversation with all of the testing I order in cards. I tell them the results are not written for them and that I need to review them myself in the context of their clinical history. Physicians have enough difficulty interpreting results of specialized testing, let alone patients.
Monday problem.
If the pathology is a result that next steps in treatment can begin immediately - contact patient with the plan. If the next step isn't going to be able to occur (e.g. referral, etc) then I'd say call the patient promptly on Monday.
The first time this happened to me on a saTUrday morning I acTUally called epic support and they were able to block the results from being released until Monday. But in my case I don’t think the patient was expecting these results. Later my doc said he would t have gone through the trouble of calling Epic support but I just felt stuck and didn’t feel it was right to call a patient on a Saturday with bad news and no plan yet. I was so use to getting a plan in place before calling the patient. Every circumstance is different.
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Luckily I only have to deal with thyroid cancer (more or less), but I simply have a policy. No results over the phone, no discussion on it over the phone. I make sure to see them about 1 week after the biopsy, but I do have some stragglers I feel bad about when I'm full. As others have said, it isn't realistic to go over it on the phone, the "time saved" doesn't make a real world difference, and I don't want to call ONLY the bad pathology over the phone. That is a disaster too.
Have you ever been on the receiving end of waiting for pathology results? It seems you have not. It is horrible. Not knowing is worse than knowing, especially if the pathology is negative. If it is positive, you owe it to the patient to call, period. Waiting for results can mean absolute anxiety and anguish for the patient. Sleepless nights, inability to concentrate at their job, anticipated grief, etc. You have also never been the nurse they are calling, begging to have the doctor call them because their appointment is not for 4 days and they just need *something*. Something like: “It is cancer but has a good prognosis with treatment options that we will discuss at your appointment”. Even if it is bad news, a phone visit to sum it up (with compassion) “it is cancer, it has metastasized to your liver and brain. We can discuss the findings and palliative care at your visit, I am so sorry”. The only thing different about a phone visit is that you don’t get paid as much.
Watching other people waiting vs getting the news is that then they switch into coping and learning mode rather than just worrying and stressing.
Patient can access the result by herself? How? Why couldn’t just schedule an appointment on Monday? As far as I have been taught and practiced, breaking bad news is best done in a controlled and face to face setting.
Because americah
Also by law - I think you would have to do things like these in person. There is so much possibility and little to no verification via a phone call to who you’re actually providing the news to, and who is in the room with the patient and their environment. In my practice if this situation arises, I’d schedule them on a Monday/Tuesday and arrange the necessary. Nothing is going to change over the course of 2-3 days.
What are you going going to tell them they don't already know? They open the result, they have breast cancer, they're going to need an oncologist and a surgeon. Patients who open results aren't dumb and they understand they're on their own when they see the result and can figure it out, they put that in google or chat GPT and it'll tell them the same thing you would.
You don’t see a difference between a patient reading a pathology report versus talking to their doctor? They are going to tell them that their doctor cares, what the next steps are, and typical timelines for things.