A 36-year-old woman presented to her gynecologist with a primary complaint of right breast pain. After examining the patient, the gynecologist scheduled both an ultrasound exam of the breast and a mammogram. The mammogram was completed five days after the patient’s appointment with the gynecologist. The results of the mammogram were normal, and the outcome was reported to the patient.
Subsequently, the patient failed to appear and cancelled multiple appointments for the ultrasound. The gynecologist’s office made multiple attempts to contact the patient to schedule the ultrasound, including several phone calls to discuss the importance of conducting the ultrasound. The staff also followed up with a certified letter, which was never claimed. The attempts to schedule the ultrasound were documented in the patient’s chart.
The patient presented to her primary care practitioner several times after the mammogram for symptoms that were unrelated to gynecological treatments. Her complaints to the primary care physician included weight gain and bloating, anxiety, and sore throat. She did not contact the gynecologist’s office nor keep any scheduled gynecological appointments during this time.
The patient returned to the gynecologist’s practice nine months after the initial visit with a new complaint of a lump in the right breast. An ultrasound of the right breast was performed in the office with findings consistent with fibroadenoma. A mammogram was performed showing a two centimeter nodule in the breast nodule. A surgical biopsy revealed an infiltrating ductal carcinoma. The patient alleged a delay in diagnosis of breast cancer.
There are numerous reasons patients might be non-adherent with diagnostic testing recommendations. Many people fear a cancer diagnosis, especially breast cancer. Prior experience with cancer patients (e.g., parents, siblings, or close friends) might cause a patient to delay seeking diagnosis and treatment. Though early detection has led to an increased survival rate for those diagnosed with breast cancer, perceptions of cancer treatment (including surgery, radiation, or chemotherapy) and its side effects may prevent a patient from undergoing further diagnostic testing, even when the results of a mammogram are normal.
Low health literacy might also contribute to non-adherence with diagnostic recommendations. Health literacy is defined as the ability to obtain, process, and understand health information to make appropriate health decisions. Patients with low health literacy might not understand healthcare discussions and the implications of recommendations. Factors that increase the risk of low health literacy include advanced age, poor English proficiency, lack of high school education, and low socio-economic levels. However, even highly educated patients might have difficulty understanding healthcare-specific communications.
The Agency for Healthcare Research and Quality (AHRQ) funded the development and validation testing of a short assessment of health literacy in both English and Spanish.1 This simple test can be administered in two to three minutes and can identify patients who may require greater assistance and time for explanations and instructions. Techniques such as Teach Back2 are beneficial in evaluating the patient’s understanding of follow-up care, testing recommendations, medication administration, and other healthcare instructions. Teach Back involves asking the patient to repeat instructions in his or her own words. Another technique to assess the patient’s understanding of the need for testing is the AskMe3® program developed by the National Patient Safety Foundation.3 The program encourages patients to better understand their health conditions by asking their providers three questions:
If a patient becomes distant, difficult to treat, or non-adherent with treatment plans, it is beneficial to examine the source of the behavior. Many patients are hesitant to admit their fears or lack of understanding. A patient’s emotional status and health literacy may lead to lapses in care that negatively impact his or her health status.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.