Risk Management

Timely Referrals: Reducing Your Risk

By Byron H. Demorest, MD

Argus, November, 1991

Timely and appropriate referral of a patient for subspecialty care beyond your area of expertise is fundamental to responsible patient care and prudent risk management. But when you’re deeply engrossed in an effort to save a patient’s eye, it can be easy to forget that another ophthalmologist may be better equipped to treat the patient. Remember, however, that the patient himself may come to the conclusion that a better result might have been reached if he had been referred to the specialist before serious complications were allowed to develop.

A case from the OMIC files helps to illustrate this issue. A cataract surgeon was referred a patient whose eye had been repaired for a traumatic corneal laceration four months earlier. As the eye seemed quiet, an apparent uncomplicated cataract extraction with implantation of an IOL was performed. On the third postoperative day the eye became photophobic and very uncomfortable. The physician noted cells and flare in the anterior chamber and felt that the patient had an iritis. Vision was foggy and it was noted that the pupil did not dilate with Atropine. On the fourth postoperative day an aqueous tap was obtained since it appeared that the media was becoming cloudy. Nothing was found on culture. On the sixth postoperative day the vitreous was opaque. It was only at this point that the patient was referred to a vitreo-retinal surgeon who performed a vitreous tap and instilled intraocular antibiotics. The eye became phthisical and was lost. The claim was settled with an indemnity payment.

The ophthalmologist who is wise enough to know when to refer a difficult problem for specialty care often prevents a malpractice action. Referring a patient to a colleague does not indicate a weakness or inability on the part of the referring physician. Nor should the fear of losing a patient to another physician be a factor. The overriding concern here must be to give each patient the best possible care – the same care you would want if you were the patient.

Always consider referral of a patient under any of the following circumstances:

When you are working with a medical or surgical problem that is outside your area of expertise.

When the patient refuses to follow your instructions for eye care.

When, in spite of your best efforts, a patient’s eye is doing poorly.

Caring physicians usually know instinctively when to seek help for difficult problems. Patients rarely sue doctors who communicate and show compassion. Don’t wait for the patient to seek another opinion. Get it yourself before it’s too late.