Beware of the Helpful Referral

Case history

Dr X was approached informally by Mrs A, the secretary of one of his colleagues, to write a referral for her 23 year old daughter to undergo an abdominal tap under CT guidance and blood tests. Mrs A, who Dr X knew well, said that her daughter had developed increasing abdominal pain over the preceding three months and that Dr Y, her daughter's GP, had ordered an abdominal and pelvic ultrasound. The ultrasound was reported as showing pockets of fluid throughout the daughter's pelvis and abdomen, with the report concluding “cannot rule out ovarian primary.”

Mrs A told Dr X that she had been reviewing various internet sites and was concerned that her daughter may have ovarian cancer. Mrs A said that her online research had led her to conclude that the fluid collections needed to be drained for cytology and that her daughter should also have blood tests.

Although Dr X thought it odd that the daughter was not going to follow up with her GP, he nevertheless ordered a CT-guided tap of the fluid collections and various blood tests (including tumour markers for ovarian and bowel cancer). When Dr X asked for the GP's details so that the results could be sent to Dr Y, Mrs A asked that the results be sent to her instead and that she would “take things from there”.

Two months later, Dr X was attending a ward round at the hospital when he ran into radiologist, Dr Z. Dr Z asked how Mrs A’s daughter was going “in light of her dreadful pathology”. When Dr X said he did not know what Dr Z was referring to, Dr Z informed him that the fluid deposits in the daughter’s abdomen had been diagnosed as peritoneal mesothelioma.

When Dr X contacted Mrs A to find out how her daughter was, he was informed that the daughter’s condition was terminal and that the peritoneal mesothelioma was in its advanced stages.

Medico-legal issues

Several weeks later, Dr X received a letter from the Australian Health Practitioner Regulation Agency (AHPRA) informing him that Mrs A had lodged a complaint about his failure to follow up the investigations that he had initiated. Dr X was asked to provide a written response to the complaint, in addition to a copy of his clinical notes for the patient.

Dr X found he was unable to provide a comprehensive response to the complaint, and was forced to concede the circumstances in which he had referred the patient for pathology and radiological investigations. The Medical Board was extremely critical of Dr X’s conduct in relation to:

1. ordering diagnostic tests in circumstances where he had not consulted with the patient.

2. not following up the results of the investigations ordered.

3. breaching the patient’s privacy by noting that the investigation results were to go to Mrs A and not to Dr Y or the patient.

Discussion

This case exemplifies the importance of being careful when informally facilitating the care or management of a friend or colleague. In this instance, Dr X ordered diagnostic tests of a serious nature knowing there was a likelihood that the results could be sinister and in circumstances where he was not assured that the GP (or another doctor) would be involved in the patient’s ongoing management.

In addition to this, by noting on the forms that the results were to go to Mrs A, Dr X breached the patient’s privacy, as health information was going to be provided to her mother without her express consent. The Medical Board of Australia has published Good Medical Practice: A Code of Conduct for Doctors in Australia (the Code)¹ that sets out what is expected of all doctors registered to practice medicine in Australia. Although the Code is not intended to be an exhaustive study of medical ethics, it contains guidance for doctors who find themselves in situations such as Dr X. For instance, in addition to patient assessment and formulating and implementing a suitable management plan, the provision of good patient care includes facilitating continuity of care and maintaining adequate records (neither of which Dr X did). The Code also reminds doctors that in most cases, it is inappropriate to provide care to close friends, colleagues and/or family members for various reasons, including possible discontinuity of care.

In addition to the ethical issues surrounding the treatment of friends and family, Members should be aware that their Professional Indemnity Insurance Policy does not indemnify them for claims that arise out of the provision of elective medical treatment to immediate family members.

If you find yourself in a position such as this and are uncertain as to whether you should write a referral for a colleague, friend or family member, contact our 24 hour Medico-legal Advisory Service on 1800 011 255 or email advice@mdanational.com.au.

References
1 Good Medical Practice: A Code of Conduct for Doctors in Australia. Available at: www.medicalboard.gov.au/Codes- Guidelines-Policies.aspx.