Communication key to reducing liability risks with specialty referrals
Robin L.Altman, M.D., FAAP
Pediatricians and the Law
When referring a patient to a specialist, the pediatrician is requesting advice or
direct patient care usually because the patient’s condition is outside the pediatrician’s
expertise. The consultation process is a valuable tool for a primary care provider
and medical home.
There is no guarantee, however, that the parent or guardian will comply with the recommendations.
If the patient has an untoward outcome because consultation with an expert did not
occur with the proper timing, the referring doctor could face medical liability consequences.
A general pediatrician examines a 1-month-old patient, becomes concerned about a dull
red reflex and refers the patient to an ophthalmologist. At the 2-month checkup, leukocoria
is evident. The pediatrician learns that the parent, not understanding the urgency,
has not yet seen the consultant. An urgent consult is completed within two days, and
a retinoblastoma is diagnosed.
A general pediatrician examines an 8-year-old with persistent asthma, becomes concerned
about a possible dietary allergy and refers the patient to an allergist. The parent
plans to schedule the appointment over a school vacation. Before that happens, the
patient is hospitalized with anaphylactic shock.
Explaining to the parent the reason for and importance of the referral, tracking whether
the patient actually saw the specialist, and communicating with the specialist can
help safeguard against liability risk.
Failure/delay in referral or consultation is one of the top 10 medical factors in
pediatric malpractice claims involving diagnostic errors. Nearly half of claims with
referral problems end in malpractice payouts. Usually, a patient is referred by a
generalist to a specialist. Sometimes, however, a specialist may refer a patient to
a physician of a different specialty.
Evidence supports that co-management of care between specialists and primary care
providers results in better health outcomes for patients with chronic diseases.
The referral process begins with the decision to refer and choosing the correct specialist.
The decision to refer varies widely among primary care providers and is influenced
by many factors such as the nature of the presenting problem, the patient’s expectations,
the provider’s experience with the condition and practice style, and the practice
environment. Choice of a consultant should be based on the specialist’s expertise
and competence, and may be limited by the patient’s health insurance plan.
Even though health care providers value communication, patient surveys indicate that
problems with information transfer occur frequently. According to studies of specialty
referrals, there was no communication between providers either before or after the
consult was performed in about half of referrals.
Timeliness and thoroughness of information transfer is extremely important. Up to
70% of specialists have rated the background information they received as fair to
poor. Inadequate information transfer can result in the specialist not knowing the
reason for or urgency of the consultation, which can delay its completion.
Approximately 50% of referring physicians do not know whether their patients have
actually seen the specialist to whom they were referred. This gap in the referral
process can be associated with delay in consultation completion, inefficient care,
worse patient satisfaction and liability risk.
While it may be somewhat labor intensive, referral tracking is an important task for
the referring provider because it is the only way to know with certainty that the
patient saw the specialist and when. Utilizing the same electronic health record (EHR),
as occurs in multispecialty groups, allows for ease of information transfer and referral
tracking between providers. Occasionally, however, the parent may choose to see a
different provider than the one recommended, creating additional obstacles for these
Obstacles to patient compliance
Communication lapses among physicians, their patients and other health care providers
frequently are the focus of malpractice claims. Common claims for noncompliance with
referrals include that the physician did not stress the importance, fully explain
the reason, clearly indicate the potential bad outcome or explicitly state that a
referral is necessary as opposed to optional.
Risk management strategies for referring physicians
Clearly explain to the parent the reason for the referral and whether you are concerned
about something potentially serious; document this conversation in the medical record.
Communicate to the specialist the reasons for the consultation and indicate the degree
If the potential health concern is time sensitive so that failure or even delay in
obtaining the specialist’s assessment likely will cause injury to the child, then
a phone call directly to the consultant is appropriate and can facilitate scheduling
an appointment. In this case, it is particularly prudent for the pediatrician to track
Consider a system for tracking referrals (e.g., a suspense file or EHR follow-up list
for all pending referrals), which includes making reminder phone calls, scheduling
follow-up appointments or calling parents to discuss consultant recommendations. It
is important to include a backup plan for intervening if a referral is not completed
in the expected period of time.
Document the follow-up plan, further discussions with parent and/or consultant, phone
calls and review of consultant’s letters (e.g., written initials and the date or e-signature/attestation
in the EHR, etc.).
Dr. Altman is a member of the AAP Committee on Medical Liability and Risk Management.