Over the years, single-physician treatment has evolved from the rule into the exception. These days it’s common for the typical patient to see several different physicians on a regular basis — e.g., a cardiologist for high blood pressure, a neurologist for migraines and a family practitioner for general care.

Such arrangements, however, may lead to confusion regarding the nature and extent of each individual treatment relationship, thus resulting in frustrated expectations and potential professional liability exposure.

Discuss treatment boundaries
In a limited physician-patient relationship, the objective generally is either a second opinion, or treatment for a designated medical condition— which implies treatment for a specific and typically brief period of time.

While the referring physician maintains the primary advisory role in the shared decision-making process of general care and treatment, the role of the consulting physician is much more focused and very clearly defined.

Unfortunately, these different roles aren’t always clear to physicians and patients:

• Consulting physicians may erroneously assume primary care responsibility after a consult with a patient.
• A consulting physician may be expected to diagnose and treat a specific medical condition but does not act beyond offering his or her opinion.
• The patient assumes his or her relationship with the referring physician is over once the consulting physician becomes involved.

Up-front communication can prevent such misunderstandings. For example, when a general practitioner sends a patient with a lung mass to a pulmonary specialist for a consultation, the GP should make clear to both the patient and the specialist whether the consultation is merely for a second opinion or is for evaluation and treatment of the condition.

If the consultation is for the latter, all parties must be clear regarding follow- up care—specifically, that the specialist will assume responsibility for both diagnosis and treatment of this specific issue.

If the consultation is strictly for a second opinion, then the resulting doctor- to-doctor relationship exists only for the purpose of providing additional information to the referring physician.

In both cases, all communication must be directed back to the referring physician so that he or she may fulfill the obligation to discuss the various treatment management options with the patient. Further, consulting physicians must advise patients that all medical information will be provided to the referring physician—who maintains primary responsibility for evaluation and treatment, as well as for the complete medical record.

It is essential that both referring and consulting physicians discuss treatment boundaries with the patient, and document these discussions in their respective medical records. It is also important to document acknowledgment of the patient’s understanding of this discussion.

Prevent physician-to-physician communication gaps
Any gaps in physician-to-physician communication can potentially compromise a patient’s health. For instance, when a patient arrives at a consulting physician’s office without a preliminary workup—including test results and notes—the consulting physician must guess why the patient is there. It is especially difficult to fathom what the referring physician had in mind when the patient presents with multiple medical problems.

A good way to avoid this serious breakdown in communication is for the referring physician to place one or two office staff in charge of all referrals. It would be their job to forward relevant materials to consulting physicians prior to the patient’s scheduled appointment.

Among the items to be forwarded are the following:

• purpose of the referral
• history of the problem—including exam findings, test results and treatment history
• relevant medical/family/social history—including diagnoses, treatments and allergies
• referring physician’s expectations regarding urgency, treatment, advice and recommendations.

It is important that referring physicians refrain from sending patients to consulting physicians with an order for a particular procedure. This is offensive to consulting physicians, who expect to perform their own evaluations of patients and offer their own expert advice.

As for the initial request for a referral, communication by mail, e-mail or fax is appropriate in nonurgent cases. More urgent requests require verbal interaction, such as through the telephone or personal contact.

Of course, physician-to-physician communication is a two-way street. It is crucial that the consulting physician send back a report to the referring physician as soon as possible. One good approach: On the day of the patient’s visit, the consulting physician faxes a short form (with diagnosis) to the referring physician and, if warranted, the intended treatment plan. The full report should then be forwarded as soon as possible.

For their part, primary care physicians might consider setting up a system to ensure that patients’ medical records are not filed again until test results, reports, etc., are returned by consulting physicians.

Conclusion
In limited physician-patient relationships, discussion and documentation of treatment boundaries are absolutely essential in coordinating communication and ensuring that the patient receives the proper overall medical care. Physicians should always stay within the communication framework of a limited relationship; exceeding the relationship’s limitations may result in increased liability exposure.