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Patient Referral

Case Study

What Happens When You Don't Refer a Patient

After suffering health issues associated with a tumor, a disgruntled patient sued his naturopath, citing lack of referral and diagnosis.

Ray Morton was a 48-year-old roofer who weighed 250 pounds when he first sought the care of Brian Williamson, ND, in 2013. On the intake forms, Morton indicated he was experiencing low back pain that radiated into both legs and feet. After taking a complete history, which revealed nothing out of the ordinary, and completing an exam, Dr. Williamson decided to proceed with naturopathic care without ordering X-rays or conducting additional testing.

Dr. Williamson recommended a dietary supplement to reduce inflammation. He also used an herbal tincture that included Valerian extract and white willow bark extract to relieve muscle spasm and decrease pain.

Morton reported that his pain appeared to have lessened after receiving this treatment, so Dr. Williamson asked him to schedule three appointments for the following week as part of a course of naturopathic care. However, Morton did not make these appointments, saying he would “check his schedule and call back later.”

Three years later, Morton returned to see Dr. Williamson for a second time. He reported low back pain radiating into his legs and feet similar to the discomfort he had experienced three years prior. He said the pain started shortly before his appointments, but he didn’t know exactly what movements or activity brought it on. He had stayed on the supplements for three months and then didn’t seem to need them anymore. Morton continued to see Dr. Williamson for naturopathic care, which included hydrotherapy and homeopathic treatments, on-and-off for five years. Morton’s treatment was intermittent in nature because he didn’t see the need for a regular course of naturopathic care. According to Morton, Dr. Williamson’s treatments helped the pain subside, and that was good enough for him. Dr. Williamson saw Morton a total of 33 times between 2013 and 2018, whenever his back pain worsened.

The naturopathic care on each occasion continued to include hydrotherapy and homeopathy. Dr. Williamson also used heating pads and ultrasound on Morton each time he was treated. Morton denied seeking care from any other health care provider during that time, other than seeing his internist to manage his hypertension and to be put on a weight-loss program.

Patient Seeks Care with Another ND

Morton did eventually see another ND, Dr. Chris O'Riley, when Dr. Williamson went on vacation in August 2018. Now 56, Morton’s back pain had flared up, and he didn’t want to wait until Dr. Williamson returned. 

At Morton’s first visit with Dr. O’Riley, the ND provided care similar to that given by Dr. Williamson. Dr. O’Riley continued to treat Morton in a similar manner for 4-5 visits. However, when Morton’s symptoms persisted, Dr. O’Riley referred him for an MRI to rule out a disc herniation or a tumor. Unfortunately, the results of the MRI studies revealed a tumor that required immediate care, and Dr. O’Riley referred Morton to a surgeon.

By the time Morton met with the surgeon a month later, he was having difficulty walking due to severe back pain. Morton described the pain as excruciating, but he told the surgeon he was not experiencing any problems with urinary or bowel functions. After further MRI and CT scan studies were done at the hospital, the surgeon informed Morton he had an osteoblastoma in the spinal cord. This tumor extended down the spinal cord into the scrotum, and surgery would be needed. Morton was advised that loss of bowel and bladder function were risks of this surgery; however, without surgery, the tumor would cause paralysis or death. Feeling he had no good options, Morton consented to the surgery.

Surgery Mostly a Success

The surgery took place two weeks later and was considered a success. The surgeon was able to remove most of the nonmalignant growth. The portion that remained was located around the scrotum area. After surgery, Morton was informed that the tumor had existed for approximately 10 years. After recovering to the extent possible, Morton lacked sensation from his waist through his toes on his right side and continued to experience several health problems. He had constant urinary tract infections, felt pain and tightness in his left and right hamstrings, and was unable to control his bladder — he now had to use a catheter several times daily — and had to manually induce his bowel movements. Morton lost sexual function, walked with a limp and was unable to ambulate for long distances.

Morton Initiates a Lawsuit

Believing the ND was to blame for his constellation of problems, Morton decided to sue Dr. Williamson. The lawsuit alleged Dr. Williamson should have referred Morton for further testing and that he failed to diagnose Morton’s tumor. At this point, the NCMIC defense team met to assess the case. The team reviewed Dr. Williamson’s clinical records to determine if the allegations could be countered by proving that the proper steps had been taken, given the patient’s complaints and presentation.

Unfortunately, the records were sparse, so a well-respected naturopath in the field was retained to weigh in on the matter. The expert consultant reviewed the care rendered by Dr. Williamson. He was lukewarm at best due to Dr. Williamson’s management of Morton’s care. The naturopathic expert consultant felt that this case would be difficult to defend for the following reasons:

  • While he didn’t think it was a breach of the naturopathic standard of care to fail to order an X-ray when Morton presented in March 2013, Dr. Williamson’s failure to refer for imaging during the five years Morton received naturopathic care from him was inexcusable.
  • The expert consultant also opined that the persistent low back condition, even though treatment was rendered intermittently and was met with some success, should have been followed up with referral or further testing to determine the source of the symptoms.
  • Dr. Williamson’s records did not reveal repeated evidence of exacerbation due to trauma. Therefore, this expert felt that Dr. Williamson’s level of suspicion regarding the source of the symptoms should have been heightened and should have led Dr. Williamson to seek further testing.

The Impact of Policy Limits

Another factor in the case was that Dr. Williamson carried policy limits of only $100,000, which could leave his personal assets exposed in the event of a judgment in excess of $100,000. The potential for this escalated when the NCMIC-assigned defense attorney estimated the potential damages Dr. Williamson could face if the case went to trial. Among other things, these included:

  • $64,867 for past medical expenses
  • $55,000 for future medical expenses
  • $123,000 for past wage losses
  • $315,000 for future wage losses
  • $500,000 for pain and suffering
  • $200,000 for loss of consortium

What’s more, Dr. Williamson’s low policy limits would restrict the doctor’s options because there would be less room for negotiation and a compromise settlement.

Settling the Case

Considering the inadequate documentation, the less-than supportive opinions from the naturopathic expert and concern that a judgment could exceed his policy limits, Dr. Williamson agreed to attempt to settle the case. After several days of going back and forth with Morton’s attorney, the case was settled for below Dr. Williamson’s policy limits. NCMIC spent close to $45,000 to defend the case.


What Can We Learn?

Compliance

It is obvious that Morton was not a very compliant patient. However, the responsibility of ensuring proper care is still the obligation of the licensed healthcare provider.

Red flags

When a doctor sees a patient with “pain radiating into both legs and feet,” it should be a red flag of a potentially serious condition — no different than “weight loss and thirst” would prompt a clinical suspicion of diabetes. Physicians who see patients with these symptoms should be triggered to consider additional diagnostic testing. In this case, had additional testing been performed, the patient’s outcome might have been different.

Cooperation and consultation

While he was being treated by Dr. Williamson, Morton also was being seen by his internist for hypertension and weight loss. Ideally, Dr. Williamson would have had a working relationship with this physician. Regardless, he could have called the internist to discuss their mutual patient. Such a call might have generated a discussion about the patient’s symptoms and his reluctance to comply that would have elicited further testing.

Guidelines

While the clinical perspective on whether films are needed for every patient has changed considerably over the past decade, there are still times when a doctor must consider additional diagnostic evaluation. In this case, Morton’s weight, age, symptoms, non-compliance and type of occupation all should have been indicators of the need for further evaluation.

Low Policy Limits

Review your policy regularly and select limits that not only protect your patients but also yourself in the event of a malpractice allegation. In this case, the doctor had very low limits of coverage that left his assets exposed and restricted his options. His low policy limits left less room for negotiation or a compromise settlement.

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