Handling the "Compare with Priors" Request

“Please compare with priors.”

When I first saw such writing on a script for an imaging-study, I was a little offended. What sort of hack did the referring clinician think I was, to imply that I might otherwise not review previous exams?

My attitude changed as I saw that, in the real world, people unfortunately do cut corners, whatever their motivations. I considered that “please compare with priors” was meant to be a plea to such individuals, and started patting myself on the back that I, and indeed most of the colleagues with whom I worked, were superior sorts, who behaved professionally without needing to be asked.

Such self-congratulation was fleeting. Before long, I was encountering cases where, despite the “compare with priors” request, my facility had no priors for comparison. Ordinarily, this would be no biggie, as most patients do not have priors; one routinely takes cases, checks for priors, sees none, and proceeds to read. But now, the clinician’s request creates a conflict! He’s telling me there are priors, and wants them compared. I ignore the request at my peril.

So, the first step is to double-check the fileroom. Are we sure there are no priors? Really, really sure? Could the patient have had a name-change, or a duplicate file? Better scour the place, rummage through adjacent patients’ folders, etc. Still none? Well, now we have to choose who to bother next. We can ask the patient, hoping that he’ll correctly remember what sorts of studies he’s had before, and where. Hopefully he won’t recall having a prior at our facility, since he’ll then think that we’re horribly disorganized and have lost his valuable study.

How about calling up the referring doc? After all, he’s the one who told us there was a prior; he or someone in his office should be able to look in the patient’s chart and tell us where and when it happened. If it was at another facility, they might even be able to get it sent to us. On the other hand, do we want to hassle their office with our issues? It’ll take them time to look up the patient’s file. What if they, too, believe the prior study was at our place, and lose faith in our ability to conduct our own affairs?

In many of these instances, the search is fruitless, for the patient had no prior study after all. The culprit turns out to be the doc (or nurse) who wrote out the script; the individual always writes “please compare with priors.” Just in case there are any. Would you want to ask such referrers to, pretty please, knock it off? I know I wouldn’t.

Optimists (and some investors) tell us that these issues will be eliminated once we institute shiny, expensive, high-tech electronic medical records. I’m a little more cynical. Even if an error-free universal system got implemented tomorrow, we’d still be referencing pre-EMR records for years and years.

In my last mammography practice, I developed a solution - not foolproof, of course, but pretty effective. Since mammo is particularly prior-film dependent, patients making appointments were asked if they’d ever had mammos elsewhere, or if they’d signed out films from us and not yet returned them. “Yes” answers prompted a cascade of follow-up queries and offers of assistance from our staff in getting the patient’s old films to our office.

The priors almost always got to us before the patient’s appointment, and could thus be merged with our own film-jacket before the radiologist ever received the study for interpretation.