The responsibility of a specialist to make a referral to another specialist — or instead 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 of the gentleman’s primary care physician. 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 shows a note on it written by Dr. G: “Called pt needs colonoscopy in three yrs.”
Though the physician assistant 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 primary care physician or Dr. G.
Some two 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 one 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 4 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 though 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 three 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, primary care physicians and their screening specialists should know what to expect from each other. And when the findings are significant, direct contact among the health care providers — instead of reliance on communications to third parties — will help eliminate incorrect assumptions.
Author Gordon Ownby is General Counsel for the Cooperative of American Physicians, Inc. (CAP).
If you have questions about this article, please contact us. This information should not be considered legal advice applicable to a specific situation. Legal guidance for individual matters should be obtained from a retained attorney.