Are Fears Of Losing Patients Preventing Appropriate Referrals?

While a variety of issues may contribute to a reluctance to refer patients for some physicians, ensuring appropriate and timely referrals can facilitate optimal patient care and go a long way toward preventing potential malpractice lawsuits.

Strong professional bonds with loyal patients are not uncommon for many clinicians but sometimes even with the best intentions to treat every patient, it is just not possible. What happens when you need to refer to another doctor due to a complicated diagnosis? While you may have a database of trusted colleagues to whom you refer, is there also some anxiety that you may lose a patient to a referred physician? Alternatively, a lack of a timely referral could also result in a malpractice case, costing the physician time, money and potential damage to a good reputation. After interviewing several podiatrists, it is clear there are mixed feelings on this controversial topic.

   “My personal opinion is that it is human nature to be paranoid about losing patients to a competitor’s podiatry practice,” says William Fishco, DPM, who is in private practice in Phoenix. “Firstly, we are podiatrists and secondly, we are businessmen and women who want to protect our practices.”

   While some physicians completely understand the fear of losing patients or diminishing business in one’s practice, others simply find that those who fear such loss need to form more trustworthy relationships.

   “In my opinion, (a practitioner who fears the loss of a patient) probably has developed poor collegial relationships or very few relationships. This coupled with any insecurity issues would make that doctor reluctant to refer,” adds Bryan Markinson, DPM, an Assistant Professor of Orthopaedics and Pathology at the Mount Sinai School of Medicine in New York.

Why Would There Be A Reluctance To Refer?

Understandably, podiatrists want to protect their practices as there are some cases in which doctors do lose patients or experience severe miscommunication when treating a patient, which can quickly sever a relationship.

   Desmond Bell, DPM, shared a story about referring to a vascular surgeon after detecting progression of a patient’s peripheral arterial disease. The patient had ulcers on her feet and legs, due in part to paraplegic status. After the initial assessment, Dr. Bell suspected that a bypass was necessary. The patient complied and went to get the opinion of the vascular surgeon. She returned to Dr. Bell several months after the next scheduled appointment, having had a below-the-knee amputation unbeknownst to Dr. Bell. The vascular surgeon also continued wound care on the remaining lower extremity without any communication with Dr. Bell. While the patient did return, Dr. Bell notes that any further care on the remaining limb should have been with him as he was the original physician. As a courtesy, the vascular surgeon could have at least noted the need for amputation rather than a bypass.

   “Poor communication can cause many problems that could easily be prevented. A two-minute courtesy call can build trust and goodwill, and is a great marketing tool as well,” explains Dr. Bell, Co-Founder and Executive Director of the Save a Leg, Save a Life Foundation.

   Aside from losing patients, there may be other contributing factors to a podiatrist’s reluctance, including an element of defeat due to the inability to treat the patient.
“Reluctance to refer a patient to another podiatrist may be in part fear of criticism of care, loss of the patient and the income that comes along with it, and finally, the feeling of failure in that he or she could not provide the service that was needed,” notes Dr. Fishco, a faculty member of the Podiatry Institute.

Malpractice: What Could The Fear Of Referral Ultimately Cost?

Though fear of losing business, failing to treat the patient or criticism from peers may be motivating factors to avoid referrals, there is one very important reason to refer patients — malpractice.

   One of the worst scenarios for any physician is a malpractice lawsuit. Lack of a timely referral truly isn’t worth the risk of a lengthy, costly court battle.

   “It is an ever present fact that in all risk management courses, podiatrists are encouraged to refer to reduce the chance of allegations of malpractice,” says Dr. Markinson.

   In the August 2007 issue of Podiatry Today, an article (“Seven Keys To Preventing Malpractice Lawsuits”) included a case in which the jury awarded a patient $1.23 million because a podiatrist failed to refer him to a vascular surgeon in a timely manner. He went to the podiatrist for severe vascular insufficiency and ischemic foot ulceration. He received antibiotics and the podiatrist scheduled him for a return visit two weeks later. At the next visit, the podiatrist referred the patient to a vascular surgeon for consultation 17 days later. The patient went to a local emergency room with a necrotic foot before seeing the vascular specialist. After subsequently undergoing a below-the-knee amputation, he filed a lawsuit against the podiatrist and won.

   “(Given that) medical malpractice actions are founded upon real or perceived poor results, the failure to refer implies or suggests that the adverse outcome from treatment could have been averted with timely referral,” explains Allen Jacobs, DPM, FACFAS, who is in private practice in St. Louis. “Anyone with experience in the review of such matters will confirm that not infrequently, the subsequent treating physician, particularly when he or she is an orthopedic surgeon, will suggest either overtly or in a sub rosa manner that the previous treating doctor was negligent.”

Key Advantages Of Referring

To avoid malpractice and provide the best possible patient care, it is important for podiatrists and doctors in all specialties to form relationships within a network of trusted colleagues. Working within a team and utilizing network referrals can truly expedite patient care.
“From a medical/legal standpoint, it makes sense to refer to specialists rather than hold on to the medical ‘hot potato,’” says Dr. Bell.

   If something goes wrong for any reason and you knowingly did not refer the patient in a case in which you could not adequately treat him or her, you open yourself up to a plethora of legal battles.

   “My advice to those who are reluctant to refer is stick to what you do best. Even though you would like to handle everything for your patient, refer anything and everything out that you are not comfortable handling. My residency director always used to say, ‘you don’t want to be the only one carrying the coffin,’” says Dr. Fishco. “I refer out on a regular basis. For example, I have never mastered arthroscopy. When I have a patient whom I feel would be better served with arthroscopy rather than an open procedure that I am comfortable doing, I refer him or her to my DPM colleagues who can do a good job for the patient.”

   When you refer to others, you also create a referral network in which those providers will refer back to you, thus increasing your patient network and business. It also creates a sense of trust, which should make you feel more comfortable referring to colleagues with good working relationships. According to Dr. Bell, providers also talk to colleagues to find physicians in any given specialty for referral. With strong relationships in other specialties, you could become the one receiving patient referrals.

   “Having a professional relationship with a provider increases the chances that you will also receive a referral from the colleague of that provider,” notes Dr. Bell.

   David Armstrong, DPM, MD, PhD, has extensive experience referring out to other doctors, who refer back to him. This is a very common in his practice at the University of Arizona and was proven advantageous to him at a very young age through his father’s podiatry practice.

   “Having grown up with podiatry in my father’s office, I can tell you that I would routinely visit many doctors in our community around the holiday season, thanking them for referrals and they would thank my father in return. This was a mutually beneficial situation in an individual practice like my father’s and I can also tell you in a very large academic practice, it is essential for our future,” says Dr. Armstrong, a Professor of Surgery and the Director of the Southern Arizona Limb Salvage Alliance (SALSA) at the University of Arizona College of Medicine in Tucson, Az.

   “So many times people are sued not for what they did but for what they didn’t do. I think the more open you are in sharing your patients and getting the overall largess from the intellectual and diagnostic power in your community, the better off you’re going to be.”

   To be fair to colleagues and also show your gratitude when patients are referred to you, some physicians like to rotate referrals. In Dr. Bell’s practice, they commonly rotate referrals, especially when admitting hospitalists are involved. Spreading the referrals around to several different areas allows the referring physicians to form trusted relationships with multiple colleagues across all specialties and in several different practices or hospitals.

Emphasizing The Documentation Of Referrals

Impeccable record keeping can only help both the patient and the clinician. Documenting the condition and treatment of the patient in the podiatrist’s care, as well as the referral information, will keep the podiatrist protected. The referral information should include:

• Reason for a referral based on the initial assessment of the patient
• Referral doctor’s name, address and phone number
• Whether the patient was informed of the urgency in seeking further care

   It may be time-consuming to document every detail about a patient’s referral but in the long run, it will help the patient follow through with appropriate treatment and show that the physician was not neglectful.

   “We document if the patient has been informed of the need for urgency in seeking such referral and informing the patient of the potential sequela of failing to follow through with such referrals. A copy of the progress note is sent to the primary care provider (PCP), and with the permission of the patient, to the referral healthcare provider,” explains Dr. Jacobs.

   All of these protective measures ensure that the patient gets the urgent care needed. They also protect the referring physician by showing a proactive method for continued treatment.

   “The whole risk reduction principle hinges on documenting the referral, documenting that the consultation occurred and documenting the outcome. That means your office has to determine when the patient will be seen and that he or she was seen, and it is incumbent on you to get a report from the referral physician what the outcome was. These areas are serious weaknesses in failure to refer cases in which a patient in fact does not follow through and you did not know about it. Any plaintiff’s attorney can seize on that, making you look unconcerned, sloppy, et cetera,” says Dr. Markinson.

In Summary

As a physician, the ultimate goal is to make sure the patient receives the best possible treatment. Dr. Fishco shared a success story about a 63-year-old female patient who presented with pain in her fifth metatarsal. She had also been suffering from lower back pain and was getting epidural injections and physical therapy. Dr. Fishco suspected an element of peripheral arterial disease.

   “I referred her to a vascular surgeon, who called me after seeing her, and said that she had severe aortofemoral arterial disease and had scheduled her surgery for the next week. The patient came back to see me a few months later and just wanted to thank me for saving her life,” says Dr. Fishco.

   Overall, the DPMs who were interviewed for this article reported that 90 percent of all their referral patients returned to them after more specialized treatment with another physician. With those odds, some may find it surprising that some physicians still have a fear of losing referred patients.

   As for the others who don’t return, “frankly, some of the 10 percent I would just as soon not see again,” adds Dr. Jacobs.

   All of the interviewed DPMs would agree that the fear of losing patients is no reason to prevent appropriate and timely referrals. As long as the referring physician is sure to document the referral information and initial consultation, it is likely that a satisfied, trusting patient will return for further follow-up treatment.

   “The bottom line is that it’s not about us but about the patient. If the patient feels more comfortable with the other doctor and wants surgery done by him or her, so be it. All that really matters is that the patient gets taken care of and the outcome is good,” says Dr. Fishco.

   For further reading, see “Building Referrals And Relationships With Primary Care Providers” in the July 2005 issue of Podiatry Today or “Referral Generator: Work Smarter At Patient Education” in the April 2003 issue.