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Organizing Follow-ups


Mark A. Hurt MD

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Now for an unpleasant subject: organizing follow-up cases. You know what I mean. These are the cases I cannot sign-out the same day I receive them. I have to do something else to them. Experience shows that my way of dealing with them is probably not your way of dealing with them.


This is my philosophy of how to deal with follow-up cases.


1. Always keep them moving. One of the big problems in closing out cases is that some are more difficult to assimilate and interpret. At the initial evaluation, one might have to order a panel of immunostains, after which, during the second evaluation, there are more questions requiring more stains or an internal consultation (or both) before the report is finally written and released. There is an inertia that must be overcome to keep these kinds of cases always moving, because they often require substantial amounts of time to complete.


2. Always do them in numeric order, from oldest to newest. You might be surprised and pleased to learn that you will hardly ever receive a telephone call from an irate clinician if you are always working on the oldest cases first. Although it seems as though it is common sense, it isn't. Often, earlier in my practice, I did them randomly. This was a mistake. What I learned was that the random approach selects for the less complicated cases before the more complicated ones. There is a reason that the more complicated cases are also the oldest cases; it is because when they are more complicated they require more stains and internal consultation with colleagues in order to complete them, which also makes them late -- and inspires the ire of clinicians who want them finished.


3. Never pass over a case if it is too difficult. This is very important. Learn to always make a decision on a case, even if you don't know the diagnosis. My approach is that if I cannot sign it out, then I need to recut it, stain it, or consult on it (or perhaps all of these) -- if at all possible. It is not an option to set it aside and do nothing; you will still be at the same place tomorrow if you take that approach. Furthermore, if you have a system for action, you will be thinking about the case while it is being processed further. Often, when it comes back, you will have a fresh approach to the case and more data on it to help with the evaluation.


4. Always document in the computer or laboratory information system (LIS) information about the status of the case. In my experience, if a clinician knows why a case is delayed, he is much more understanding than if he doesn't know why. Often the secretaries are the front line in dealing with such questions, so it is very helpful for them to know this information, and it keeps the office tension at bay.


5. Keep a 7-workday list. As the name implies, all cases that are older than 7 working days show up on the list. I suspect that similar lists are kept in other laboratories. The practical result is that you will know the outlying cases -- and the goal is not to have a case show up on the list unless there is a good reason.



I am curious to learn how others approach the problems of follow-up cases and late cases.
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Dr. Mona Abdel-Halim

Posted

Very nice blog really... I nearly have the same protocol. The problem, I go home with those difficult cases buzzing in my mind until they get closed!!!! Sometimes, I can't sleep.
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Dr. Phillip McKee

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When I worked ar Brigham and Women's Hospital in Boston, once a specimen had been logged in by the lab, a ticking clock started. I would receive the slides the next day and the policy that I had to follow was that 90% of cases had to be signed out within 24 hours. If a case couldn't be diagnosed, a hold note had to be generated explaining to the clinician why the case couldn't be diagnosed e.g. immunohistochemistry, special stains, deeper levels or an internal/external consultation etc was required. One daily checked the un-reported cases and this was also monitored externally. If you didn't get that 90% result, you were in serious trouble. It worked very well.
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