Legal Pearls: Failure to Refer A Patient to Needed Specialist

One of the most important decisions that a primary care physician (PCP) can make is knowing when to refer a patient to a specialist. Patients sometimes ask for referrals themselves, but often it is up to the physician to decide to refer a patient for specialized care. Because a primary care physician can’t be a specialist in everything, it is essential to understand when you need help to properly diagnose or treat a patient.

Clinical Scenario

The physician was a 69-year old general practitioner with a small practice. Over the last few years, in anticipation of retirement, he had been scaling down his practice somewhat and had stopped taking new patients. The physician had been in the same location for the last 30 years, and still saw his long-standing patients, some of whom had been with him for decades.

One of his long-term patients was a 40-year-old man who had been a patient of the physician for almost 20 years. While most men in their early 30s don’t go to the doctor very frequently, this patient was always concerned about his health and had been having check ups regularly since he was a young man. Now 48, the patient had some of the issues that plague the middle-aged: he was about 20 pounds overweight and had elevated blood pressure, for which he took medication. The PCP had been trying to encourage him to lose weight and eat better.  

Over the years, and increasingly as he got older, the patient would come to see the PCP (or sometimes call on the phone) concerned that he had a dangerous or urgent condition. If the patient had a headache, he immediately assumed that he was having a stroke. If he had a bad cold, he was sure it was pneumonia. Luckily, in the years that the PCP had been treating the patient, the physician had come to understand his nature and was generally able to reassure him when he came in with complaints which he attributed to a terminal condition.

And so, the PCP was not surprised when his patient came in one day with chest and upper back pain, speculating that he was having a heart attack. A brief examination revealed nothing out of the ordinary, but discussion with the patient revealed that he had worked out the previous day.

“I’m trying lose weight and exercise like you said, doc,” said the patient.

The PCP reassured the patient that his discomfort was undoubtedly due to straining himself while working out.

“You can’t just jump into it,” advised the physician. “You have to start slow and build up, so you don’t injure yourself.”

Relieved, the patient went home. But over the next 9 months he returned 6 more times with similar complaints of chest pain radiating from his chest to his neck to both of his arms. On one occasion he reported shortness of breath.

Each time, the PCP was able to establish that the patient might have done something which would have caused discomfort, and he was thus able to reassure the patient, who, satisfied, went home.

A few weeks after the last visit by the patient, the physician got a call that the patient was in the hospital after suffering a massive heart attack. A week later, the patient died.

The PCP felt terrible about his patient’s death, particularly since the patient was in his 40’s and left a wife and 3 young children. When he was served with papers notifying him that he was being sued, he was worried, but not surprised.

NEXT: The Legal Case