Referral Back to a Poor Primary Health Care Provider

A 24-year-old woman arrives in the emergency department complaining that she has felt dizzy for the past month. On this occasion, she was in town shopping when she felt dizzy, and her mother brought her in. She had seen her family doctor previously because of the dizziness, but he was unable to help. She reported that she originally sought this physician's help for a heart problem and that he had prescribed a number of medications.

Among these are drugs for weight reduction: Synthroid (a thyroid prep­aration), phenmetrazine (an amphetamine-like compound), and caffeine. In addition, she was placed on a diet of 500 calories per day. The patient is now obviously underweight and very agitated. Her blood pressure is 200/135 (very high), and her pulse rate is 100 (high). In addition, serum electrolytes (blood chemistries) are markedly abnormal, and her electrocardiogram shows ST-T abnormalities.


The emergency physician decides to admit the woman to the hospital. He calls her private physician — who is on staff — and suggests that the medications he prescribed have gotten the woman in trouble. The physician refuses to consider this possibility. Should the emergency physician still admit the patient to her private physician, knowing that there is a good chance that the same regimen that got her into trouble will be continued? Or should the patient be admitted to another physician, possibly provoking the medical staff?

Commentary

The emergency department physician has a duty to the patient in hand to provide appropriate health care. Having spoken with the primary care physician, he has deter­mined that the family doctor will not reconsider his current therapy.

This situation involves not merely a difference of medical opinions where a range of options might well be acceptable. In this case, the emergency physician believes the previously pre­scribed treatment to be a serious and immediate threat to his patient's well-being. He should arrange admission to the hospital to an attending physician whom he believes to be competent to diagnose and treat the patient properly.


This position can be supported primarily on grounds of two essential principles of (medical) ethics: beneficence and autonomy. The first principle requires that the physician judge the benefits and harms to the patient incurred by alternative paths to diagnosis and treatment. In this case, the emergency physician believes that the prior medical regimen itself is, at least, partly responsible for the problems that brought the patient to the emergency department.

He cannot then judge it to be in her best interest to continue to receive what he regards as harmful medical treatment. From a slightly different perspective, failure to recommend an alternative course of action could be seen as a negligent failure to provide "due care".


At the very least, it is the emergency physician's duty to inform his patient of the diagnosis, that is, that her symptoms are partially or completely explained by her med­icines and her diet, the implications of the diagnosis (the risk of serious malnutrition, heart attack, stroke, sudden death, and the like), and his recommendations for treatment (discontinuing the present regimen with hospitalization and therapy to correct her problems).

If it is assumed that the patient's metabolic disturbance is not yet so severe as to have impaired her ability to reason, the patient may then (autonomously) decide whose recommendations to accept. One might also argue that since she is not in a good position to assess the conflict between the physicians and since her general health is so threatened by her current condition, only informing her about a contrary diagnosis and treatment plan is insufficient.

That is to say, the emergency physician might have a duty to (paternalistically) urge the patient to accept hospitalization under a physician other than her family doctor. As she cannot readily appreciate the medical risks of her diet and her drugs, one might well conclude that the emergency physician has a responsibility more compelling than simply to present information. Just how far such a duty extends depends on the degree of risk under the circumstances.


In this case, the professional duty to act to preserve the patient's proverbial "life and limb" could be seen as strong enough to overcome, temporarily, the conflicting obligation to respect any hesitancy the patient might have to disregard her personal physician. This position is bolstered by the fact that the woman sought another opinion by presenting herself for care in the emergency department. Evidently, she perceived that her difficulties were insufficiently attended to by her family doctor.

However, she might have feelings of loyalty to or trust in the previously consulted doctor that could cloud her judgment in the short run. In the end, one would justify asking her to accept different care on the grounds that she could, under less emergent circumstances, weigh all the considerations later and make up her own mind about whose care she wished to accept.


The case does not present much of a moral conflict for the emergency physician. His duty to the patient requires him to refer the patient to someone who will provide medically acceptable care. This is not to say the political problem of "provoking the medical staff" should be taken lightly.

It could be argued that alienating the staff might produce negative repercussions for the emergency physician, such as termination of his appointment or formal discipline, and that such an outcome would, in the long run, adversely deny others the benefit of his competent practice. Such abstract concerns, however, must take a back seat to the immediate consideration of the consequences of denying proper care to the sick patient.

Rather than worrying about provoking the staff because of an imagined breach of professional etiquette, the emergency physician should be concerned with how best to explore the possibility of substandard care by a staff physician. Physicians have a duty to maintain practice standards both to prevent direct harm to identifiable patients and to promote trust by patients in the medical profession generally. In addition, hospital bylaws and / or state or local laws may require that physicians report incidents of suspected malpractice or incompetent care.


From this perspective, the emergency physician has a duty to find out if other doctors in the community have found other patients who have received improper care from the family physician in question. If such cases were identified, hospital authorities (administrators, credentials committies) should be alerted. In some areas, it would also be appropriate or necessary to alert a medical practice board or similar licensing or oversight agency.

Hospitals, if not individual physicians, have a responsibility, under malpractice law, to maintain the quality of care practiced in their institutions. Doctors, as members of the hospital community, are key agents in protecting the stan­dards of care and cannot be excused on grounds of disliking conflict, be it political, economic, or interpersonal.

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