Malpractice Case: One Common Danger When Making Referrals

Gordon T. Ownby


October 05, 2018

Medscape Editor's Key Points:

  • The medical record needs to provide clarity, whether it's viewed by the primary care physician or any specialist.

  • Primary care physicians and their screening specialists should know what to expect from one another.

  • When medical findings are significant, direct contact among all physicians can help prevent incorrect assumptions.

Make Referral Communication Clear

The responsibility of a specialist to make a referral to another specialist—or instead to rely on the primary care physician—will depend on a number of variables. But at the very least, the medical record on the issue should avoid ambiguity.

A 58-year-old construction superintendent was referred for a colonoscopy by the physician assistant (PA) of the man's primary care physician (PCP). Prior to the actual colonoscopy, Dr. G, a gastroenterologist, performed a rectal exam and felt an immobile, depressed lesion with firm edges approximately an inch from the anal verge. During the colonoscopy, Dr. G first used forceps and then a snare to obtain specimens for pathology.

Dr. G dictated his report immediately after the procedure and described finding and removing the lesion, which "had all the characteristics of a malignancy." In the recommendation, Dr. G noted: "After receiving the results of the biopsies, I will call the patient. I do believe that the patient needs a surgical consultation regarding the rectal lesion which is about one inch above the anus."

The next day, the pathologist diagnosed "fragments of tubulovillous adenoma" and commented: "Complete excision of the lesion is recommended if clinically indicated." Dr. G's copy of that pathologist's report showed a note on it written by Dr. G: "Called pt needs colonoscopy in three yrs."

Though the PA at the family medical group received copies of both Dr. G's procedure report and the pathologist's report, he did not feel further action was necessary given Dr. G's notation on the pathology report. The PA did not discuss the matter with either the patient's PCP or Dr. G.

Some 2 years later, the patient went to a new PCP at a different medical group and requested a colonoscopy. That colonoscopy found a mass that was firm, brittle, growing outward, and ulcerated. The recommendation of the new gastroenterologist was for the patient to follow up with the PCP, a colonoscopy in 1 year, and a surgical referral for possible surgery on the rectal lesion. Two colorectal surgeons had further tests performed, leading to a recommendation of chemoradiation prior to surgical resection of the area. Pathology after the surgery noted adenocarcinoma of the colon with involvement in four of 14 nearby nodes.

In his subsequent lawsuit, the patient sued Dr. G and the primary care medical group employing the PA.

In his deposition, Dr. G testified that he recollected advising the patient on the day of the colonoscopy that he needed to see a surgeon and later telling the patient's wife over the telephone that although the pathologist's report showed no adenocarcinoma, her husband should nevertheless see a surgeon. The patient and his wife denied any such advice, and the record reflected only Dr. G's simple note on the pathology report about advising the patient to get a follow-up colonoscopy in 3 years.

Dr. G and the primary care group employing the PA resolved the matter informally with the patient prior to a binding arbitration.

The ability of a specialist to make further specialist referrals—such as to a surgeon—will differ among practice arrangements. As a routine, however, PCPs and their screening specialists should know what to expect from each other. And when the findings are significant, direct contact among the healthcare providers will help eliminate incorrect assumptions.

This case comes from Medicine on Trial, originally published by Cooperative of American Physicians, Inc., to provide risk management lessons from litigated case histories. The article was originally titled "Specialist Referrals – Make Sure the Plan Is Clear."


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