Referral, Referral; Who's Got the Referral?

I love Medical Economics. I have been a devoted reader ever since residency. Not only did I find it fascinating enough to read cover to cover, but in those first few years I occasionally found checks (made out to cash, with no fancy fine print below the endorsment line committing me to three years of credit protection) tucked somewhere in the back. I didn't recognize the shameless marketing tactic back then, but I would have read the magazine anyway. I still devour each issue, though I now often skip over the finance articles. It's too depressing to read about stocks and mutual funds when I can barely pay myself.

One of their features is a column called Malpractice Consult; an advice column written by a malpractice attorney. After all these years their answers kind of blend into a general refrain of "document out your ass." I get it. I do it (mostly.) Because I began reading MedEc so early in my career, I've been running scared from the git go, so it's taken me a while to relax a bit and realize that although anyone could sue me, most people probably won't. The lawyers' chorus bleating "You Never Know," while technically accurate, has begun to feel like just a scare tactic, reinforced by the benign outcome of my single malpractice suit.

Malpractice Consult has taught me that I'm responsible for a lot of things related to medical care (which also need to be documented out my ass.) Suits have been brought for "Negligent Prescribing"; I need to explain the what-when-why and potential adverse effects of every single prescription I write. Suits have been brought for "Failure to Diagnose"; I'm supposed to document my thinking about every diagnosis I consider, what I did to rule it out or why I decided not to -- for every patient's every problem, every time. And suits have been brought for "Negligent Referral."

Not just "Failure to Refer in a Timely Fashion", "Inappropriate Referral" (to the wrong kind of specialist) but "Negligent Referral": sending someone to someone else who screws up. Apparently it is also my responsibility to keep tabs on the quality of care (per Dr. Bob, a simple, easily implemented concept) provided by the consultants I recommend.

Ok. Fine. I get the idea. Frankly, though, the only means available to me to express any dissatisfaction I may have with any given specialist is to withhold future referrals. But sometimes even that isn't enough.

I have three local options for ENT referral: a solo and a 2-person practice that I like very much, and another 2-man practice that I don't like. Not because they're younger/newer, but because I don't trust them. Why? For starters, the letters they send me always document a full head and neck exam on every patient, even when some maneuvers were clearly not done. (How do you perform a Rinne or Weber test on a two-year-old? And why would it be necessary when he's being referred for nosebleeds?) They write "Thank you for your referral" on self-referred patients, presumably so they can bill the visit as a "Consult" instead of as a much less lucrative "evaluation and management" visit. Other patients have confirmed that documented procedures weren't actually done. Another patient who met the senior guy in the hospital (where I have no control over the admitting doc's referrals, as I'm not on staff there) told me he was a "cocky little bastard." Suffice it to say, I don't refer to them.

However twice on recent occasions, imagine my surprise when patients went there instead of to the office I recommended (and documented.) Although awkward, I asked them why, and got answers like "Well, my dad goes there so I thought I'd try them." So much for my considered medical judgement about consultants. What could I say?

I'm not really worried about the lawsuit angle, because I've clearly documented that my referral was to A and not CLB. But the guy gave a toddler double the recommended dose of an antibiotic (and gave me lip when I called -- politely -- to point out his error) and then sent the kid for an infectious disease consult for a non-condition I had been explaining to the parents for weeks. She did fine with the tonsillectomy, but geez; what's a poor dinosaur to do?

I suppose I could refer you...