When a doctor does not refer a patient to a specialist for additional care, for more diagnostics, or for treatment that only another physician can provide, he or she may be considered liable for negative consequences the patient suffers as a result. Not getting the specialty care needed can cause a patient to have a delay in diagnosis, to have a condition that worsens, and to end up with a lot of other complications.

Not referring a patient is not always considered negligence in medicine, but it can be, and when a patient suffers because of that preventable mistake, a malpractice case may be filed. If you believe your doctor should have referred you to a specialist, you may want to speak to a medical malpractice attorney to determine if your case is strong enough to lead to a settlement.

Referrals in Medicine

A referral is often used in medical care to ensure patients have access to specialty care as needed. Any time one medical professional recommends a patient see another, it is referred to as a referral. There are many reasons to do this: to provide the patient with a specialist who can provide better care, to involve another specialist in making a diagnosis, to give the patient access to treatment that is more specialized, or to send a patient for a specific type of diagnostic test.

In HMOs, or Health Maintenance Organization insurance plans, patients must get referrals in order to see anyone other than their primary care provider (PCP). Failing to get an official referral from the PCP may lead to a lack of coverage of costs for the additional service. This leaves the patient dependent on his or her PCP to provide referrals as necessary.

What is a Failure to Refer?

A primary care provider has an important responsibility to determine when a patient’s needs goes beyond their ability to provide good care. These doctors are generalists, which means that there are instances in which a patient needs a professional with more specialized knowledge and experience, such as a surgeon, a cardiologist, or a radiologist.

When a primary care provider does not give that referral, either at all or in a timely manner, and the patient suffers as a result, it is considered failure to refer. There may be cases in which the damages caused by the failure to refer were found to be unavoidable. However, there are also many instances in which the harm could have been prevented if the physician had provided a timely referral.

When Failure to Refer is Negligent

Any case of medical malpractice must prove four things in order to be successful. In the case of a failure to refer, it must first be established that the doctor who did not provide a referral had a duty to provide reasonable care for the patient, including any needed referrals. Then it has to be proven that by not providing a referral, the doctor breached the expected standard of care for the patient. Finally it has to be shown that the breach caused harm and damages to the patient.

In the case of a failure to refer, a legal team making a case for malpractice must demonstrate that another, similar doctor would have made that referral, thereby avoiding the harm to the patient. This is usually accomplished by using expert witnesses who can show that they would have done something differently in the same situation, such as provide a specific referral for the patient.

Consequences of Failure to Refer

When a doctor does not provide a referral in time or at all, the patient may suffer a number of serious complications. The number of complications and the severity depend on the individual and the health issues at stake. Some possible consequences of a failure to refer include:

  • Delay or failure to get a diagnosis.
  • Delay in treatment.
  • Worsening health conditions.
  • Additional health conditions.
  • Worsening and additional symptoms.
  • More medical expenses.
  • Pain and suffering.
  • Emotional distress.
  • Hospitalization.
  • A need for surgery.
  • Loss of ability to work.
  • Temporary or permanent disability.
  • Death.

For some patients the failure to get a referral may have minimal or no consequences, but for others the result can be devastating. Not referring a patient can be a very serious mistake that doctors should not make.

Examples of Failure to Refer Cases

Malpractice cases often cite more than one reason that a doctor or other medical caregiver was negligent, and failure to refer is one of them. An example includes a case in which hospital staff failed to order diagnostic tests and to refer a patient to a cardiologist. He was admitted to the hospital for knee surgery but became disoriented and anemic. The staff failed to order tests or to refer him to a specialist and went ahead with the surgery. He died two days later from myocardial ischemia, a lack of blood flow to the heart. The patient’s family filed a medical malpractice suit and was awarded $8.25 million by a jury during trial.

In another case the lawsuit settled before going to trial involved a patient who went blind because a referral was not given. The patient was examined several times by an ophthalmologist and optometrist, but no one referred him to a specialist for a laser treatment that he needed to correct his vision. Eventually the treatment was performed, but by then it was so delayed that the patient suffered bleeding during the procedure and was left blind. He was able to get a settlement of $1,275,000.

The consequences of not being referred to a specialist, either at all or soon enough, can be as serious as death or severe disability, as in these two examples. The complications of not getting a referral vary widely by patient, but in general the results are not good for the patient. Specialty care is important and patients trust their primary care providers to make sure they get the care they need. If you were not referred to a specialist and you believe your doctor failed to make that referral negligently, you may be interested in filing a malpractice case. Let an experienced lawyer help you through the process to ensure it will be successful.