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            When a primary care physician refers a patient to a specialist to assist with ascertaining a diagnosis and developing a treatment plan, their involvement with the patient’s care does not necessarily come to a hault.  Although a specialist is arguably better equipped to handle a patient’s complaints, it may not be reasonable to rely on a specialist’s opinions.  If the patient later claims their condition was misdiagnosed or treated inappropriately, the primary care physician can often targeted in a lawsuit just as a specialist is.  There have been several recent medical malpractice cases which illustrate the importance of communication, documentation, and follow up by the primary care physician in the area of patient referrals. 

            In a Massachusetts case, a pediatrician avoided liability for a misread by a radiologist by accounting for and relaying his suspicions about his patien’ts ongoing condition directly to the radiologist.  In that case, a twelve year old patient presented with complaints of left leg pain when exercising over a period of month.  The radiologist interpreting the x-ray films of the pelvis reported that they were normal. The minor patient’s condition, dislocation of the femur, then went undiagnosed for 22 more months and she continued to experience pain.

            In support of a claim of medical malpractice, the plaintiff claimed that the x-ray film showed dislocation of the upper end of the femur.  The plaintiff claimed that by misreading the x-ray film, the dislocation went undiagnosed and progressed causing permanent bilateral hip deformity and difficulty ambulating. 

            The plaintiff chose to focus their claim of negligence in that case against the radiologist.  The pediatrician avoided becoming a defendant because there was evidence that the pediatrician had advised the radiologist that he included dislocation of the femur in the differential diagnosis, and that he reasonably relied on the interpretation of the radiology films to rule out that condition.  By articulating his thought process in the medical records and in his request for a radiology referral, the pediatrician made it clear that he was considering dislocation as a diagnosis.  In providing this information to the radiologist, the pediatrician alerted the radiologist of a possible error in his x-ray interpretation and a potential need to do re-testing.  If the pediatrician did not clearly outline the basis for his treatment plan and differential diagnosis, he may have likely  been added as a defendant in the case for failing to take reasonable steps to diagnose the dislocation. 

            In a Florida case, both an internist and a family practitioner were found negligent for failing to diagnose a patient’s pregnancy, which the patient claimed resulted in her failure to seek prenatal care and lead to the premature birth of her child.  The patient in that case presented to the family practitioner with complaints of nausea.  She sought treatment from the internist several weeks later complaining of nausea and absence of menstruation.  At that time, neither physician recognized that she was four weeks pregnant.  Four months later, she went to see the family practitioner again reporting an additional symptom of lactating from the breast.  The family practitioner believed these symptoms were related to a thyriod problem and did not order any pregnancy testing.  When the patient returned to the internist with stomach pain, he ordered a sonogram which showed that she was seven months pregnant.  Her baby was born two weeks later at 37 weeks with severe respiratory problems. 

            The patient brought a medical malpractice case against both the family practitioner and the internist claiming that they failed to diagnose her pregnancy.  In their defense, the physicians argued that the cause of the premature birth was unknown and that pre-natal care would not have changed the course of events.  The physicians also pointed out that the patient had a history of missing her menstrual cycles.  The family practitioner testified that it was his understanding that the patient was being seen by an ObGyn at the time she presented for treatment.  The internist claimed that the patient told him her husband was sterile.  However, there was no supporting data in the medical records to confirm that either of the physician’s claims were true. 

            The jury found the internist 75% negligent and the family practitioner 25% negligent.  The patient and her minor child were awarded a total of $884,500 in damages including past and future medical expenses, rehabilitation expenses, future loss of earning capacity, past and future pain and suffering, and loss of consortium.  The family practitioner was defending her actions in this case partially based upon her belief that the patient was being treated by an ObGyn, and her reliance on this specialist to treat her for possible pregnancy.  In light of this case, physicians who are relying upon specialists to assist with treating a patient’s symptoms, should take efforts to confirm that an expert is involved and then communicate with this expert to ensure that the expert is providing the appropriate treatment.  All such investigatory efforts and communications should be fully documented in the medical record.  Simply relying on a patient’s claim that an expert physician is involved and doing the right thing to treat the patient will make an internist or family practitioner vulnerable to a lawsuit if an adverse outcome results.

            A recent New Jersey case alleging the failure to timely diagnose breast cancer also serves as a reminder that blindly relying upon another physician to make necessary treatment efforts may not be reasonable.  In this case, a patient filed a medical malpractice suit against an ObGyn and a radiologist for not taking appropriate steps to investigate a reported lump in her breast.  The patient, who had a history of fibrocystic disease of the breast, complained of a lump in her right breast to her ObGyn.  The ObGyn examined her and referred her to a radiologist for a mammogram which was interpreted as normal.  No further treatment was provided.  A mammogram taken a year later when the complaint of a breast lump continued showed suspicious findings.  After a mastectomy was performed the presence of cancer was confirmed. 

            The patient claimed that the ObGyn had a duty to biopsy her breast based upon the finding of a lump on exam.  She also claimed that the radiologist negatively interpreted her x-ray films as normal without ordering additional films when she had a history of a lump.  Although the ObGyn denied that he found a lump on examination, there were conflicting entries in the medical records including the radiology referral which stated there was a lump in the right upper outer quadrant.  The radiologist contended that in light of the history of a lump, he reasonably believed a biopsy would be ordered quickly by the ObGyn and that he had no reason to order additional testing. 

           Although the jury found both the ObGyn and the radiologist negligent, they found only that the ObGyn’s negligence increased her risk of harm.  They awarded her over three million dollars and damages and the case was later settled for an undisclosed amount. 

            In this case, the defendant ObGyn placed too much reliance on a negative radiology report despite the inconsistent history given to the radiologist.  The radiologist failed to communicate with the ObGyn to ensure that proper follow up care was going to be given despite the normal mammogram film.  Based upon this failure to communicate directly, neither physician ordered any additional testing which was needed to diagnose the patient’s potentially deadly condition.  When physicians’ findings are joined together to come up with a diagnosis, direct communications are extremely important, especially when misdiagnosis may be a question of life or death.  These communications should be fully documented so that the thought process leading to the consensual treatment plan is clear.  By not directly communicating, physicians are at risk for making incorrect assumptions about follow up care.

Healthcare Law, Litigation & Public Policy   Medical Licensure & Discipline ♦ Employment Board of Registration

Referral to a Specialist

by Attorney Frank E. Reardon

October 2001