When a specialist treats a referred patient, making clear who will be managing particular aspects of the patient’s ongoing care can help avoid finger-pointing down the road.
The Case¹
A 61-year-old lawyer began treatment with Dr. IM, an internist, and had a prostate specific antigen (PSA) blood test drawn. Dr. IM telephoned the patient with an elevated result of 7.12 and referred the patient to a urologist. When the patient returned to Dr. IM six months later, he reported that he had undergone a prostate biopsy at a cancer center. The result of the biopsy was negative, but he told Dr. IM that his prostate size was 120 grams.
Eleven months later, the patient saw Dr. IM for his annual checkup and reported that a second biopsy taken at the cancer center came back negative, except for a few transitional cells. At the next year’s checkup, the patient told Dr. IM that he was being followed by his urologist for an elevated PSA of 9.
During the next year’s checkup, Dr. IM ordered a PSA, which came back at 6.37. But after another visit to Dr. IM three years later (now six years since the patient’s first visit to Dr. IM), the patient’s PSA was 13.2 – elevated but within the fluctuation range for benign prostatic hypertrophy. Nevertheless, Dr. IM referred the gentleman to Dr. U, a urologist.
Dr. U performed a cystoscopy and wrote to Dr. IM that the patient’s PSA was 17.7 and that a prostate biopsy showed benign prostatic hyperplasia without malignancy. In his letter, Dr. U attributed microscopic hematuria to a transitional cell carcinoma of the bladder, which he resected. Dr. U closed his medical comments to Dr. IM by stating the patient “will require surveillance cystoscopy” for the bladder, but he did not offer who would be following the patient’s prostate issues.
The patient returned to Dr. U roughly every four months for cystoscopies. Dr. U did not obtain any PSA levels after the initial consultation, though a draw ordered by Dr. IM the next year showed a value of 8.03. Several months later, Dr. U resected another bladder tumor. When he last saw the patient two years after that (which was three years after the initial consultation with Dr. U), the patient had no symptoms of cancer.
But two months later during a business trip, the patient experienced extreme pain in his lower back, left leg, and foot. When he returned home, he saw Dr. IM, who ordered a CT, MRI, and a bone biopsy. The bone scan showed osteosclerotic metastases typical of prostate cancer.
In a lawsuit, the patient alleged Dr. U failed to perform regular rectal exams and failed to order serial PSA tests following his original prostate biopsy. With serial tests, the plaintiff alleged, an elevated PSA would have prompted another prostate biopsy, leading to an earlier cancer diagnosis and treatment.
In his suit, the patient also faulted Dr. U and Dr. IM for failing to communicate with each other regarding his health. On that point, each testified in deposition that they had expected the other would follow the patient for PSA levels, based on the patient's prior experiences. The patient and Dr. U resolved the dispute prior to trial.
The Value of Consultation
This case should serve as a call to action for medical professionals to prioritize thoroughness, open communication, and collaboration in the pursuit of accurate diagnoses and optimal, comprehensive patient care. As healthcare professionals, physicians should be committed to implementing practices that prioritize patient safety and well-being. One of these practices is the duty to consult other physicians.
Consulting with other physicians allows for a broader perspective on complex medical cases, ensuring that patients receive the most comprehensive and well-rounded care possible. By seeking input from colleagues with different areas of expertise, physicians can tap into a wealth of knowledge and experiences that can enhance diagnosis, treatment planning, and overall patient outcomes.2,3,4
Collaboration also fosters a culture of continuous learning and professional growth. Through consultation, physicians can stay updated on the latest medical advancements, explore alternative treatment options, and gain valuable insights from their peers. This exchange of knowledge ultimately benefits patients by providing them with the most up-to-date and evidence-based care available.
Ethical and Legal Considerations
The duty to consult is not only an ethical obligation but also a legal requirement in many jurisdictions. Physicians are bound by professional codes of conduct that emphasize the importance of seeking input from other healthcare professionals when necessary. Failure to consult can result in legal consequences, as it may constitute a breach of the standard of care.
Consultation also plays a vital role in patient autonomy and shared decision-making. In complex cases, involving other physicians ensures that patients have access to a range of expert opinions, enabling them to make informed choices about their healthcare. By actively involving patients in the consultation process, healthcare providers can empower them to take an active role in their treatment plans.2,5
Overcoming Challenges
While the duty to consult is crucial, it can present challenges in practice. Time constraints, communication barriers, and conflicting schedules can hinder effective collaboration.
Technology, however, can help address these challenges. Telemedicine platforms, secure messaging systems, and virtual meetings can facilitate timely and efficient consultations, regardless of geographical location. Implementing these technological solutions and establishing clear protocols and guidelines for consultations can support efficient collaboration and facilitate communication amongst healthcare providers.
Conclusion
The duty to consult other physicians is a fundamental aspect of providing high-quality patient care. By embracing collaboration, healthcare providers can harness the collective expertise of their colleagues, leading to better outcomes for their patients. Physicians should be committed to supporting the healthcare system in meeting their duty to consult, enabling them to deliver the best possible care to their patients.
Robert Parhizgar, MD, MBA, MS, is a Senior Risk Management and Patient Safety Specialist. Questions
or comments related to this article should be directed to RParhizgar@CAPphysicians.com.
Sources
¹Ownby, Gordon. “The Specialist Referral: Is It a Handoff or a Consult?” Cooperative of American Physicians; 2015. https://www.capphysicians.com/articles/specialist-referral-it-handoff-o…
²American College of Obstetricians and Gynecologists. Code of Professional Ethics of the American College of Obstetricians and Gynecologists. Washington, DC: ACOG;2004.
³Snyder L, Leffler C. Ethics Manual: Fifth Edition. Ethics and Human Rights Committee, American College of Physicians. Ann Intern Med 2005; 142:560–82.
4American College of Obstetricians and Gynecologists. Physicians Working With Physicians. In: The Assistant: Information for Improved Risk Management. Washington, DC: ACOG; 2001. p. 1920.
5Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 5th ed. New York (NY): Oxford University Press; 2001