Know when to hold ’em and when to fold ’em
By Louis Sportelli, DC

Much like Kenny Rogers’ song, when it comes to treating patients, doctors of chiropractic need to “know when to hold ’em; know when to fold ’em.” Though it’s natural to want to help every patient, there comes a time when a referral may be warranted.

Consider the treatment and legal issues involved with the following situation:

A 20-year-old woman complains of lower back pain. She has a history of hematuria (blood in the urine). The DC has treated the patient, as well as her whole family, for the past eight years and has always thought of her as reasonably healthy.

Which of the following approaches would you take?

DOCTOR A

Doctor A refers the patient and coordinates care.

The visit: Doctor A knows that lower back pain and a history of hematuria in an otherwise healthy 20-year-old female could be symptomatic of urinary problems. So, she declines to treat the patient, contacts her family practitioner, and makes an appointment for the patient to be seen the same day. The patient is initially reluctant to see another doctor, but the DC convinces her that it is necessary. As a result, the patient ultimately sees the family practitioner.

Patient results: Later, the DC talks with the family practitioner and learns the patient had pyelonephritis (kidney infection). Because the DC referred her early, the patient was treated with a course of oral antibiotics and recovered within five days.

Long-term consequences: The patient and her family were pleased their chiropractor made sure she received the proper care. Plus, the family practitioner, impressed by the DC’s knowledge and follow up, referred many patients to her chiropractic practice.

Worst-case scenario: None.

DOCTOR B

Doctor B Refers the patient but doesn’t follow up.

The visit: Doctor B also suspects a urinary problem because of the lower back pain combined with a history of hematuria, and he advises the patient to make an appointment with her family practitioner soon.

The patient then asks the DC if he could treat her now, before she sees the physician, so she can have immediate relief from her back pain. He declines, offering to treat her at a later date, if the family practitioner doesn’t detect another problem.

Since the chiropractor knows the patient, he doesn’t feel a need to document the referral or find out if the patient actually saw the physician. After all, he expects to see her when she returns for a subsequent appointment.

Patient results: Unknown to Doctor B, the patient left his office feeling apprehensive about seeing another doctor. Instead, she attempted to ease the pain by doing stretching exercises at home. After the pain became more severe, she went to the emergency room, where she was diagnosed with severe pyelonephritis. She was treated with IV antibiotics, remained in the hospital for three days, and recuperated at home for an additional five days.

Long-term consequences: Though the patient was content with Doctor B’s approach, the experience made her more reluctant to seek future care. The DC correctly referred the patient but didn’t ensure she sought the appropriate medical treatment. And he didn’t coordinate the patient’s care.

Worst-case scenario: If the patient had had complications in the hospital, Doctor B’s approach may have resulted in a malpractice claim. An opposing attorney likely would have questioned the absence of documentation of the referral in the patient’s file.

DOCTOR C

Doctor C treats the patient, against his better judgment.

The visit: Doctor C also considers the possibility of a urinary condition, but he is more concerned about providing the patient with immediate relief. When Doctor C advises the patient to seek medical care, she says she only trusts him. Wanting to be the “good guy,” and against his better judgment, the DC treats the patient.

Patient results: After several treatments, the patient experienced no relief and the pain became more severe. She went to the emergency room, where she was diagnosed with severe pyelonephritis. The patient was treated with IV antibiotics, remained in the hospital for three days, and recuperated at home for five additional days.

Long-term consequences: Though Doctor C honored the patient’s wishes, this was not in her best interest. As a result, she didn’t get the treatment she needed to avoid hospitalization. Her entire family became angry with the doctor, stopped treatment at his practice, and told numerous friends about the bad experience.

Worst-case scenario: As you might imagine, Doctor C’s approach increased his risk of a malpractice suit and negative publicity, especially if the patient had ended up with ensuing complications or a life-threatening condition. Consider how an opposing attorney might try to play into the sympathies of a jury by portraying the doctor as someone who knew what he should have done but failed to do it.

THE SMART CHOICE

Choosing to refer a patient isn’t always an easy decision or one that will make you popular with patients. However, it is a step that can have a positive impact on your practice and reduce your risk of a malpractice allegation.

When you refer patients to the appropriate practitioner, you begin a process that can open up the dialogue with other healthcare providers. This dialogue can assist you in integrating care, which often can result in cross-referrals.

Louis Sportelli, DC, is president of NCMIC Group, Inc. NCMIC provides malpractice protection and offers an array of diversified financial services. For more information, call 800-769-2000, ext. 4163.

The accompanying text is offered solely for general information and educational purposes. It is not offered as, nor does it constitute, legal advice or opinion. You should not act or rely upon this information without seeking the advice of an attorney.