On September 23, a 51-year-old man came to his primary care physician and reported an inability to sleep. The patient had a history of depression, prostate cancer, laparoscopic prostatectomy to remove the tumor, and erectile dysfunction. He was taking zolpidem for insomnia.
At this visit, the patient told the physician that he was working 50 hours a week, but only getting five to six hours of sleep a night. He had also recently lost 10 pounds and reported that he was feeling “weak.”
The physician increased the patient’s dose of zolpidem and prescribed sildenafil for his erectile dysfunction.
On October 9, the patient contacted the physician’s office to request a stronger medication for insomnia. The physician prescribed eszopiclone 3 mg to be taken at bedtime. The patient was also given a prescription for alprazolam for anxiety and instructed to follow up in November.
On October 15, the patient contacted the office to request a refill of eszopiclone, as he was traveling outside the country in the coming week. He informed a nurse that the drug was more effective for him than zolpidem.
On November 3, the patient contacted the physician’s office again to request an increased dose of eszopiclone, as he was now getting only four hours of sleep a night. The physician’s office told him to come in for an appointment before the dose could be increased. An appointment was scheduled for the following week.
On November 11, the patient came to the appointment and reported continued insomnia and anxiety. He also told the physician that the sildenafil did not work for his erectile dysfunction; the physician then prescribed trimix injections, which the patient said were effective.
At this appointment, the patient completed a Patient Health Questionnaire (PHQ), a multi-purpose test for evaluating the severity of depression. The patient’s score placed him in the category of “Severe Depressive.” In the PHQ, the patient reported that he felt depressed, hopeless, and lacked interest in activities “nearly every day.”
He also reported that he had trouble concentrating and great difficulty in getting along with others or taking care of daily tasks. However, the patient responded, “not at all” to a question asking if he had “thoughts that you would be better off dead or of hurting yourself in some way.”
The physician diagnosed depression and anxiety; prescribed risperidone at 0.5 mg to be taken at bedtime; and referred the patient to a psychologist. Follow up was recommended in one to two weeks.
On November 16, the patient met with the psychologist. On a new client intake form, the patient reported that he was “not coping well” with “significant stress-related problems that did not seem to be getting better.” He also reported great fear that he was considered a “failure” by his family, friends, and work colleagues.
The psychologist recommended the patient return for weekly appointments.
On November 19, the patient called the primary care physician’s office to request a new prescription for a different sleep medication, as the risperidone was not working and gave him headaches. The physician discontinued the risperidone and prescribed temazepam at 15 mg. He also scheduled a follow up appointment in 10 days, on November 29.
On November 28, the patient died of a self-inflicted gunshot wound.
The patient’s family filed a lawsuit against the primary care physician and the psychologist. Allegations included:
- failure to properly evaluate the patient;
- failure to recognize the patient’s potential risk of suicide; and
- failure to appropriately manage his medications for depression.
It was alleged that these failures led to the patient’s suicide.
The physician had been the patient’s primary care provider for more than 10 years. In the past two years, the physician treated the patient for sporadic bouts of depression, anxiety, and insomnia. All of these conditions developed after the patient was diagnosed with prostate cancer and underwent surgery to remove his prostate.
According to the medical record, the patient was successfully treated for depression in the past with prescriptions of sertraline. The medical record did not reveal any documentation of suicidal ideation by the patient.
A primary care physician and a psychiatrist reviewed this case for the defense. The primary care physician was supportive of the physician defendant and noted that the defendant conducted an appropriate depression evaluation during the November 11 appointment. He also noted that the defendant physician was well within his role as the patient’s primary care physician to treat him for depression.
The psychiatrist was mostly supportive of the physician defendant, but did not feel that risperidone was an appropriate medication for treating severe depression. She also believed that the defendant physician should have referred the patient to a psychiatrist instead of a psychologist.
Most of the psychiatrist’s criticism was focused on the psychologist, who the psychiatrist felt did not perform an adequate evaluation of the patient’s depression. Neither consultant felt the outcome could have been prevented based on the patient’s history.
This case was settled on behalf of the primary care physician and the psychologist.
Risk management considerations
Review of a case that ended in patient suicide can put the treating physician in an unfair position. Especially in a case like this, when there was no documentation that the patient expressed suicidal ideation or a desire to hurt himself.
Primary care physicians face a variety of complex patient conditions and knowing when to refer is a key component of their practice. Referring a patient to a specialist can be especially helpful when the diagnosis is uncertain or if the patient’s symptoms do not respond to treatment. When this occurs, consider making a referral to a specialist.
When making a referral, consider these guidelines.
- Document the reason for referring the patient.
- Before contacting the other physician, explain to the patient why a referral is necessary and what the patient should expect at the appointment with the specialist. Document this conversation.
- If the referral is critical, ensure that the appointment is made before the patient leaves the office.
- Provide the patient with the specialist’s information, including address and directions.
- Contact the specialist directly. Provide information about the patient, including medical records, test results, and documents to avoid duplicate effort.
- Determine with the specialist who will manage the patient during the referral timeframe, the duration of the process, and how often to communicate.
- When consult reports or communications arrive, review the results and recommendations immediately. Document your receipt and understanding of all communications. Maintain open dialogue with the specialist to better understand and meet the patient’s specific diagnoses or needs.
- If the patient does not comply with the referral, ask the patient why at their next appointment. Document the response. Offer to find another referral or encourage the patient to comply with the original referral recommendation.1
When and how to refer patients to a fellow physician. Patient Pop website. August 9, 2018. Available at https://www.patientpop.com/blog/running-a-practice/physician-to-physician-referrals-reducing-liability-and-improving-patient-care/. Accessed January 30, 2019.