Public Health Law Map - Beta 5 - Medical and Public Health Law Site

than marketing their services to patients directly.
The most important limitation on a physician’s willingness to accept a patient is that
of a self-imposed specialty. Although there is nothing in the law to prevent a
dermatologist from practicing general medicine, most dermatologists will decline to
regulate a patient’s diabetes. In the same sense, a family physician may be willing to
treat acne and diabetes but unwilling to perform surgery. These limitations cause a
problem only if they are not known to the patient when making an appointment. For
example, a patient with severe hypertension makes an appointment with an internist.
After taking the patient’s medical history, the physician tells the patient that he limits
his practice to gastroenterology. The patient would be justified in refusing to pay for
the visit. More important, this unnecessary appointment may delay proper treatment
for the patient’s condition. In this situation, the physician should arrange for a
referral and send the patient to an emergency room if he is concerned with the delay
in seeing the second physician.
2. The Treating Specialist
Treating specialists have limited their practice to a certain specialty area but treat
patients independent of a primary care physician. This includes most of the non–
hospital-based specialties, such as endocrinology, gastroenterology, and gynecology.
The duty to treat is more stringent for treating specialists because of the prescreening
that their patients undergo. Unlike family practitioners, whose patients are mostly
self-selected, specialists evaluate a patient before determining if they will accept the
patient. Thus, the specialists have much more freedom to refuse to treat a patient,
creating a greater duty to continue treating the patient once the patient has been
accepted.
Within certain limitations, a specialist may examine and diagnose a patient without
creating a physician–patient relationship. Assuming nonemergency care and no
contractual obligations to the patient (such as MCO relationships), the specialist may
determine if the patient falls into his or her chosen area of expertise. This opportunity
to evaluate a patient before accepting him or her carries a corresponding duty to
continue treating the patient. This duty is predicated on the patient’s greater reliance
on the specialist, as evidenced by the greater amount of time and money expended to
be accepted for care by the specialist. This greater duty is tempered by the
specialist’s greater freedom to transfer the patient for complaints unrelated to the
original disease that brought the patient under the specialist’s care.
Referral is one of the most difficult judgments in specialty practice. Specialists have
a duty to continue treating a patient until the person may be safely released from
treatment or until a proper transfer of care may be arranged. The problem is the
patient who develops conditions outside the specialist’s area of expertise but for
whom no substitute physician can be found. The choice is between treating a
condition outside the specialist’s chosen area or not treating the secondary problem.
For example, assume that an obstetrician has a patient who is several months
pregnant. This patient develops serious thyroid disease, but the obstetrician is unable
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