Know When to Hold Em Know When to Fold Em

There comes a time when a patient referral is warranted.

Risk Management

Know When to Hold Them; Know When to Fold Them

Much like the old Kenny Rogers song, when it comes to treating patients, chiropractors need to know "when to hold them ... know when to fold them."


Though it’s natural to want to help every patient, there comes a time when a patient referral is warranted. Consider the treatment and legal issues involved with the following situation:

A 20-year-old enters the office complaining of lower back pain. She has a history of hematuria. The D.C. 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: Refers the Patient and Coordinates Care

The visit: Doctor A knows lower back pain and a history of hematuria in an otherwise healthy 20-year-old female could be symptomatic of urinary problems. Doctor A 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 D.C. convinces her it is necessary. As a result, the patient ultimately sees the family practitioner.

Patient results: Later, the D.C. talks with the family practitioner and learns the patient had pyelonephritis. Because the D.C. 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 D.C. made sure she got the proper care she needed. Plus, the family practitioner, impressed by the D.C.’s knowledge and follow-up, referred many patients to Doctor A's chiropractic practice.

Worst-case scenario: None

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 D.C. 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 D.C. 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: Unbeknownst to Doctor B, the patient left his office feeling apprehensive about seeing another doctor. She attempted to ease the pain by doing stretching exercises at home instead. 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 D.C. 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 would have had complications in the hospital, Doctor B’s approach may have resulted in a claim. An opposing attorney likely would have twisted his good intentions with questioning like:

Opposing attorney: “Doctor, did you think the patient needed medical treatment?”

Doctor: “Yes, I did. I referred her.”

Opposing attorney: “Doctor, where is it marked in your clinical records that you suggested a referral? And if it was critical enough for you to refer the patient, wasn’t it critical enough for you to follow up? Maybe then the patient could have recuperated more quickly without invasive, costly treatment.”

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 D.C. treats the patient.

Patient results: After receiving 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 followed the patient’s wishes, they were 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 could increase his risk of a malpractice suit, especially if the patient 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:

Opposing attorney: “Doctor, isn’t it true you thought the patient needed medical care but treated her anyway?”

Doctor: “Yes, but I wanted to help her.”

Opposing attorney: “Help her? It appears to me that another $50 visit was more important to you than seeing she got the care you knew she needed. How many times were you going to ‘help’ her at $50 a visit, all the while knowing her health was in jeopardy?”

Making the Smart Choice

Choosing to refer a patient isn’t always an easy decision or one that will make you popular with patients. Additionally, when you do refer, it can be easy to shortchange the follow-up process. However, knowing “when to hold ’em and when to fold ’em” can keep you out of the courtroom and help you build a successful chiropractic practice.

NOTE: When and if a D.C. should refer a patient is an area of differing opinion among chiropractors and a wide range of approaches is generally acceptable. These examples reflect a stricter approach to patient referrals to illustrate worst-case scenarios.


The information in the NCMIC Learning Center is offered solely for general information and educational purposes. It is not offered as, nor does it represent, legal or professional advice. Neither does this information constitute a guideline, practice parameter or standard of care. You should not act or rely upon this information without seeking the advice of an attorney familiar with the specific legal requirements of the state(s) in which you practice. If there is a discrepancy between the site and an insurance policy you have with NCMIC, the policy will prevail.