Do Doctors Have to Refer Patients to a Specialist?

Do Doctors Have to Refer Patients to a Specialist?

Doctors have a duty to refer patients to a qualified specialist if they lack the skills, training, or experience to treat the patient safely. The American Medical Association (AMA) Code of Medical Ethics Opinion 1.5.5 states that doctors have a fiduciary responsibility to support continuity of care for their patients.

Key Points:

• Referral Requirement:

  • If a doctor treats a patient who should have been referred to a specialist, the doctor is held to the standard of care expected of a specialist.

  • If the physician meets this higher standard, failing to make a referral is not considered medical malpractice (See: Simone v. Sabo (1951) 37 Cal.2d 253, 257).

• Trust and Fiduciary Duty:

  • The referral obligation arises from the trust relationship between a physician and patient.

  • Doctors are fiduciaries and must make medical recommendations in the patient's best interest.

  • Referrals should be made even if it results in loss of income for the original doctor.

• Appropriate Referral:

  • A referral must be to the best possible specialist.

  • Referrals based on friendship, business relationships, or back-and-forth referrals are highly suspect and can be criminal.

Here is some case law that provides a more in depth view of the complex referral issue.

In the case of Rios v. Bigler, the court found that there was sufficient evidence to suggest a breach of duty due to the failure to refer the plaintiff to a proper specialist. The court noted that the transfer of care to another doctor did not qualify as a proper referral, and this failure could be seen as not meeting the standard of care (Rios v. Bigler, 847 F.Supp. 1538 (1994)). The court highlighted that material issues of fact existed regarding whether the failure to refer the patient to an appropriate specialist caused the patient's injuries (Rios v. Bigler, 847 F.Supp. 1538 (1994))

In Estate of Tranor v. Bloomsburg Hosp., the court held that a referring physician could be liable for negligent referral if they knew or had reason to know that the specialist was incompetent
(Estate of Tranor v. Bloomsburg Hosp., 60 F.Supp.2d 412 (1999)). This is a variation on the theme since any negligent referral can lead to liability by the referring doctor. A real danger is when the incompetent doctor has been cross referring to the competent referring MD. This can lead to lawsuits that bypass statutory protections for physicians such as California’s MICRA law.

The case of Owen v. U.S. further supports the principle that a physician has a duty to refer a patient to a specialist when they recognize that the patient's condition requires expertise beyond their own. The failure to make such a referral can constitute a breach of duty (Owen v. U.S., 645 F.Supp.2d 806 (2009)).

In Garbaccio v. Oglesby, it was determined that a physician could be held negligent for referring a patient to a physician who cannot provide the necessary care. This implies a duty to ensure that the specialist to whom the patient is referred is capable of providing the required treatment (Garbaccio v. Oglesby, 675 F.Supp. 1342 (1987))

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