“Not My Test Results to Communicate?” Think Again.

Repurposed from the Scope, Fourth Quarter 2025

A 46-year-old married female with two adult children and one minor child became a patient at the MLMIC-insured PMD’s (primary medical doctor) office and was seen for various medical conditions over a four-year period for well care, complaints of constipation, abdominal pain and periodic problems with renal stones. She was followed several times a year for treatment of URIs, sinusitis, renal stones and prediabetes. When the patient noticed a movable dime-sized cyst on the right side of her neck, she saw her dermatologist, who referred her to an ENT. The patient never discussed this cyst or the treatment she was receiving with her PMD. However, it was recorded in the ENT’s records that the patient had a referral from the PMD’s office, rather than the dermatologist who actually provided the referral.

After the appointment with the ENT, a follow-up CT scan was performed, and the patient was referred to an endocrine surgeon for a needle biopsy of the cyst. The cytopathology reported scattered abnormal-appearing mononuclear and binucleated Reed–Sternberg cells. The overall findings were atypical and morphologically suggestive of Hodgkin’s lymphoma. The endocrine surgeon suggested admission to the hospital to remove the entire cyst.

The patient was admitted to the hospital and underwent surgery to remove the cyst. However, she did not follow up with her surgeon for the pathology results. The results were sent to the PMD, who mailed them to the patient. The patient never returned to the PMD’s office, and there was no further communication between the PMD and the patient.

Cancer Appears

Approximately one year later, after reporting what she thought was a hemorrhoid, the patient was diagnosed with anal cancer. The patient was admitted to the hospital for a PET scan, at which time she was told that she most likely had cancer in her neck from Hodgkin’s lymphoma that had metastasized throughout her body during the prior year. The patient underwent five weeks of radiation and chemotherapy for anal cancer and subsequently started treatment for Hodgkin’s lymphoma. She passed away three years later.

Lawsuit Filed

After learning of her diagnosis of Hodgkin’s lymphoma, the patient (the plaintiff) brought a lawsuit against the noninsured surgeon, their practice, the hospital where the cyst was removed and the MLMIC-insured PMD and his practice. The lawsuit alleged that the patient never received test results from anyone, including the PMD, resulting in a delay in diagnosis of Hodgkin’s lymphoma, the treatment for which required extensive chemotherapy and radiation therapy. Subsequently, the plaintiff suffered severe pain and emotional distress and lost her general enjoyment of life. The patient’s husband and family also claimed that they were deprived of her services and society, including loss of consortium.

After the plaintiff’s death, a wrongful death claim was added to the suit. At that time, the codefendant surgeon opted to settle their portion of the case for a premium amount.

Expert Reviews

Reviewers felt that the major weakness for our insured and the other co-defendants was the failure to inform the patient that she had Hodgkin’s lymphoma at the time the cyst was removed. This clearly resulted in a delay in treatment and the progression of the disease.

MLMIC retained an internal medicine expert who felt that a PMD should make referrals to specialists to address complaints, and that ends their duty. Had the patient initially presented to our insured PMD with complaints of the neck mass, it would have been incumbent upon the PMD to make the appropriate referrals, and the standard of care would have been met.

However, the patient went directly to the ENT, who ultimately referred the patient to the surgeon. The patient was treated by the appropriate specialist, and our PMD was under no obligation to contribute to the care.

Unfortunately, mailing the test results confirming abnormal lymph nodes and instructing the patient to make an appointment within one week implicated the PMD in the lack of prompt treatment. Once the results arrived in the PMD’s office, it was his duty to follow up regarding these life-threatening results. Furthermore, sending it by regular mail was not reliable enough to prove that the patient received the result.

It was concluded that the MLMIC-insured PMD deviated from the standard of care by not following up to ensure the patient was aware of the test result. Therefore, negotiations ensued, and the case was ultimately settled on behalf of our insured.

A Legal and Risk Management Analysis

Communication and Follow-up: The Bedrock of Healthcare Risk Management

The lawsuit in this case did not result from any treatment mistakes the PMD made but rather from a failure to adequately inform the patient of potentially life-altering results from a test ordered by another physician.

The plaintiff alleged that the results were never received, despite the PMD claiming they were sent via regular mail. This, the plaintiffs argued, resulted in a delay in treatment, which meant the disease progressed unchecked. What should have been a relatively simple process of communication instead became the subject of a lawsuit.

Physicians have a duty to timely relay any medical information that is relevant, especially when it is life-threatening, and failure to do so could mean facing a misconduct claim or being subjected to a lawsuit.

Adequate Communication

Absent any notification that the patient was no longer under his care, the PMD, in this case, had a duty to inform the patient of the biopsy results, despite not ordering the tests.

Mail with Follow-Up

While the physician claimed he sent the test results to the patient by regular mail, simply mailing the results to the patient, without following up to ensure the patient received and understood the findings, was insufficient. Even when correspondence is sent with a certificate of mailing, there is no guarantee or proof that the letter was actually received. While office procedures that call for standard mailing might be sufficient for notifying the patient of routine results, a method that ensures receipt by the patient is required for sharing significant test results.

Patient Portals

Today, many healthcare providers use patient portals to share test results with patients. The inherent risk that patient portals pose as the sole method of communication, however, is that providers cannot be certain that patients access and comprehend portal entries. Simply relying on portals and assuming that patients access, review and understand portal entries is an inappropriate and dangerous practice to follow. Rather, providers must ensure timely follow-up with patients to confirm receipt and provide explanations of test results, with directions on how to proceed.

Best Practices

Important information should be sent to patients by certified mail, which will generate a signed receipt for proof that the letters were actually received by patients. However, it is essential that communication with patients also consists of reaching out to them to elaborate on the next steps to address their conditions in a timely and thorough manner. A telephone conversation with a patient that is well documented can provide concrete proof that test results were discussed with the patient and that appropriate follow-up was also addressed. Documentation should clearly reflect all efforts made to clearly address positive findings so that nothing falls between the cracks.

It is important to have in place written policies that outline how to notify patients of significant test results and to ensure that results are received and understood. Thorough office protocols should be implemented and followed so that essential care is not overlooked, neglected or forgotten.

Cases such as this one illustrate the importance of having a competent and experienced legal and risk management team by your side. MLMIC’s team of experts is well versed in all legal and risk management aspects of the medical profession and is at your disposal to help you with any challenges that might arise.

MLMIC policyholders can reach out to our healthcare attorneys for questions about communicating critical test results or any other healthcare law inquiries by calling (877) 426-9555 Monday-Friday, 8 a.m.-6 p.m. or by email here. 

Our 24/7 hotline is also available for urgent matters after hours at (877) 426-9555 or by emailing hotline@tmglawny.com.

Additionally, MLMIC has created a risk management tip addressing the importance of appropriate communication and follow-up regarding critical test results. Review the tip here.

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This document is for general purposes only and should not be construed as medical, dental or legal advice. This document is not comprehensive and does not cover all possible factual circumstances. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your attorney or other professional advisors for any questions related to legal, medical, dental or professional obligations, the applicable state or federal laws or other professional questions.