You’re the Expert

Doctors have been told that the law imposes on them the standard of care of an expert if they venture into another specialist’s area. Such a legal duty would not have evolved—or survived—without medical justification. A rare pregnancy complication provides a good illustration of why a referral is important when a treating physician faces an abnormal finding.

Dr. O, an obstetrician, performed an ultrasound on the patient at 24-2/7 weeks’ gestation for complaints of right lower quadrant pain. Dr. O reviewed the ultrasound, which suggested to him a fibroid and a questionable amniotic band. At 26-6/7 weeks, Dr. O performed another ultrasound and noted a persisting amniotic band and a lower quadrant anterior fibroid with minimal changes.

At 39 weeks, Dr. O delivered the infant, who had Apgar scores of 8/9. The newborn had amputation type deformities of each extremity. The upper extremities were amputated at the elbows; lower extremities had amputations at the left knee and right hip. Subsequent treating specialists ascribed the deformities to amniotic band syndrome.

In a lawsuit that sought an award for damages for a lifetime of medical care, prosthetics, rehabilitation, and lost earnings for the child, plus emotional distress damages for the mother, the family’s attorney contended that a targeted ultrasound should have followed the first ultrasound. Once the limb deformities were observed, the family contended, Dr. O should have advised the parents of their options in terms of the pregnancy.

Dr. O did not have extensive formal training in ultrasounds and did not appreciate the significance of amniotic band syndrome with this patient. He did look for other bands, but did not look at body parts. His ultrasound sheet did not include a listing for “extremities” even though the ACOG guidelines at that time required scans for extremities in all second-trimester ultrasounds. Expert reviews of the case strongly suggested a more detailed ultrasound of the extremities after the amniotic band was identified and an informed consent discussion with the parents regarding amniotic bands. Alternatively, a referral to a perinatologist once the amniotic bands were discovered may have discharged the obstetrician’s duties.

Standard of care issues aside, the case presented another twist: What could have been done after 24 and 26 weeks’ gestation? Because the fetal injuries were not lethal, a legal abortion was not necessarily an option. Would the parents have sought out a clinic that would have performed an abortion anyway, perhaps by contending that the mother’s mental health was threatened? Even if no medical treatment were possible, didn’t Dr. O have a duty to psychologically prepare the parents for the birth of a deformed child?

It will always be the decision of the treating physician on when a referral to another specialist should be made. Physicians should remember, however, that when they decide not to send a patient to another for further evaluation, they become the expert.

Gordon Ownby, CAP-MPT’s general counsel, can be reached at gownby@cap-mpt.com.