Sam, a 70 year old healthy man, sat on the table in his urologist’s office for his one year follow up visit. Twelve months prior to this visit, Sam had bladder stones and an enlarged prostate. Dr. Rosenthal, his urologist, removed the stones and some prostate tissue during a hospital-based outpatient surgery. The surgery went well, and during the two-week follow up visit, Dr. Rosenthal informed Sam that he would not need to see him again for a year. One year later, as Dr. Rosenthal walked into the exam room eyeing Sam’s medical record he stopped for a moment, raised his eyebrows and then looked sheepishly at Sam. “I’m sorry,” he said, “the pathology report from your surgery showed prostate cancer. And, I am afraid I did not see the report until now.” Sam was confused as to how that could have happened. Although he had not previously requested a copy of the report, he asked for one now. After calming down, finding a new urologist, and making plans for the testing to find out how far the cancer had spread over the past year, Sam finally sat down and read the report. Typed in large, bold type across the top of the report was the following statement: “Results telephoned in to Dr. Rosenthal on 05/05/08″…..one year prior to the visit. Turns out not only did Dr. Rosenthal have a copy of the report, he also had received a verbal notification that Sam’s pathology report showed cancer of the prostate. The hospital had a strict policy of calling the surgeon, in addition to faxing and mailing a copy of the report whenever there was a finding of cancer. Sam’s story is one case – what happened here may not be common place, but it does occur. Although we may not think it’s our responsibility to read our operative report or a pathology report, incompetent physicians and medical malpractice claims aside, it could mean the difference between a good or bad result in the best case scenario, or life and death in the worst case scenario. In the end, your health information is just that…..yours. No one will care more about it, or own it, in quite the same way as you.

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