Knowing When to Make a Referral
Making a referral to a specialist is common in primary care medicine — after all, no one can be an expert in everything.
Ms N, aged 36 years, was a nurse practitioner who had worked out of a general practitioner's office. She saw her own patients, and she sometimes covered patient appointments for the physician, Dr M, as well. She had been working at the practice for almost a decade, and she and Dr M had a close relationship. He had been something of a mentor to her, and she respected his advice.
One piece of advice that he had given her early on was that “if you don't think you can diagnose a specific problem, you should refer the patient to someone who can” — meaning a specialist.
She understood this to be good advice, and regularly referred patients to cardiologists, gastroenterologists, endocrinologists, and other specialists. She knew that she could not be the expert at everything, and she wanted to make sure that her patients had the best outcomes possible.
One of Ms N's patients was Mrs V, aged 60 years. Mrs V came in regularly for annual check-ups, and she occasionally made appointments for minor illnesses. The patient, a postmenopausal woman, was in good overall health, did not smoke, and was the appropriate weight for her height.
Her blood pressure was borderline high, but no medication had been prescribed yet as the patient was trying to control it with dietary changes. Her only other issue was hypothyroidism, which was being successfully treated with replacement levothyroxine.
One afternoon, Mrs V came in for an appointment after complaining about abdominal pain. “I'm quite uncomfortable most of the time these days,” she told Ms N. “I thought maybe it was something I ate, but it hasn't gone away and it doesn't really feel like my stomach.…”
After further discussion, Mrs V confided that she had also been experiencing rectal bleeding. Ms N questioned her about this, but the patient's description was not consistent with what Ms N had found was the most common cause of rectal bleeding in her patients — hemorrhoids. A physical examination did not reveal anything out of the ordinary.
Ms N decided the best option was to refer the patient to a gynecologist. She explained this to the patient, and Mrs V agreed to see the specialist.
A few weeks later, Ms N was notified that the gynecologist had diagnosed a likely uterine fibroid after an ultrasound but that an endometrial biopsy was benign. The gynecologist diagnosed benign pelvic disease.
However, Mrs V began calling the nurse practitioner, complaining of continued symptoms. The patient even came into the office on two occasions to tell Ms N that she was still experiencing discomfort.
Ms N initially reassured the patient that her issues were benign, as per the gynecologist. But, after several months of Mrs V's continued complaints, Ms N ordered an abdominal computed tomography (CT) scan. The scan revealed a malignant rectal mass displacing the uterus.
Mrs V required several surgeries and was told that had the cancer been discovered earlier, she would have had a better chance of successful treatment. The patient eventually consulted with a plaintiff's attorney who advised her to sue Ms N and the gynecologist. After hearing that she was being sued, Ms N was upset but believed that she did not have to worry. After all, she had referred the patient to a specialist, so she believed her obligation to the patient was satisfied. The defense attorney provided by her insurance company told her that was not the case.
He hired a medical expert to go over the records. After reviewing the medical records and speaking to Ms N, the expert told the attorney that Ms N appeared to have been reassured by the gynecologist's finding of benign pelvic disease.
“This is an example of what we call ‘premature closure',” the expert said. “It seems that once the referral was made, the thinking stopped. Ms N should have focused on a differential diagnosis, focusing on the common causes of rectal bleeding, and this would have likely led to a timelier cancer diagnosis and a better outcome for the patient.”
After considering the expert's opinion and the costs of trial, the defense attorney recommended settling the case out of court for an amount within Ms N's insurance.
Medical experts are essential in malpractice cases in several ways. First, attorneys use them to help decide whether a case exists, in particular whether or not a clinician has strayed from the accepted standard of care. Second, medical experts are used during a trial to educate the jury members as to what the appropriate standard of care should have been for the patient and to explain the medical terminology to the jurors.
Often, both defense attorneys and plaintiff's attorneys will use medical experts to help them decide whether to pursue a trial, or whether to settle the case out of court. Medical experts are generally physicians or clinicians in the same field as the defendant (such as nurse practitioners).
Making a referral to a specialist is common in primary care medicine — after all, no one can be an expert in everything. It makes perfect sense that when a patient has an unidentifiable skin problem, he or she would be referred to a dermatologist.
Similarly, a patient who has unremitting stomach problems might be referred to a gastroenterologist. Making a referral is a good way to look out for the health of your patient and as well as your practice, because it allows you to focus on the things that are your specialty, and it allows your patient to get the help that he or she needs. In this month's case, however, we see what happens when a referral was not the best option.
Ms N intended to do the best for her patient by referring her to a specialist. Often, that is the right thing to do. But in this case, the patient was actually harmed by the fact that Ms N did not attempt to make a differential diagnosis for the rectal bleeding and abdominal pain and order a CT scan immediately.
Knowing when to make a referral and when to look more carefully into a patient's problems on your own is difficult. However, it is important to consider all options when diagnosing a patient.
Ms Latner, a former criminal defense attorney, is a freelance medical writer in Port Washington, NY.