When a patient comes into your office, it's only natural that you want to do everything you can to improve the person's health and well being. Usually, that means doing a thorough and complete chiropractic examination, detecting and analyzing vertebral subluxations, and providing a course of adjustive care best suited to that particular individual.

Sometimes, though, it becomes obvious that subluxations may not be the only health problem needing attention. While working up the patient history, taking x-rays, or giving a physical exam, you may feel that the patient has an "unusual finding" which is outside your scope of practice.

If you maintain a high standard of office procedures, you will, of course, have a Report Of Unusual Findings form available and be prepared to explain to the patient that you observed something unusual but it was not within the scope of chiropractic practice and, therefore, you cannot diagnose or treat it.

All too often, that brings a worried reaction from patients. "What is it?" they want to know. You explain again, with great patience and sympathy, that you don't know what it is because it is not something within the scope or training of chiropractic. The next question is, "Well, who should I see about it?"

By this time, you probably feel you've let your patient down. You might be tempted to make a referral to a medical doctor, a specialist (a cardiologist for example), or a non-medical professional such as a nutritionist.

Yet, if you make a specific recommendation -- to an individual provider or even to a particular type of practitioner -- you may be exposing yourself to a lawsuit for malpractice.

According to the Risk Management Foundation, "Every day physicians refer patients to other physicians for treatment. A recent federal court decision holds that the referring physician may be liable when the care provided by the other doctor is substandard."

Normally, to hold up in court, a referral has to be considered "negligent." However, one result of negligence would be if the referral delays or prevents the care needed to help the patient.

For example, you have an obese patient and make the assumption that his problem stems from poor nutrition. You refer him to a nutritionist and later he finds out he has a medical condition not directly related to nutrition. He could sue you for negligence in delaying his medical care by referring him to a nutritionist.

Medical doctors face the same risk when referring to chiropractors. According to an article in Medical Economics, if a physician refers a patient who actually needs surgery to a chiropractor, the M.D. "could be held liable if the delay leads to a worse outcome for the patient than if he'd been scheduled for timely surgery."

An added risk is that you might refer to the wrong kind of specialist. Deborah Grandinetti reported in another Medical Economics article that, in order to safeguard yourself against malpractice charges, "your selection of the specialist must be appropriate to the patient's condition. Choosing a gynecologist who wasn't experienced with cancer cases, for example, could create a liability problem for you."

Of course, the key here is knowing that your patient needs cancer care rather than general gynecological care -- a determination outside the scope of practice of chiropractic. Yet, the mere act of making a referral can be interpreted by a patient that you have preliminarily diagnosed the problem and have chosen the best route for the patient to take to treat that problem.

Finally, in cases where the treating M.D. failed to obtain proper informed consent, the courts have actually found the referring doctor liable as well.

In one case, an internist referred a patient to a cardiac surgeon. The court made the internist stand trial since it felt a jury could reasonably conclude that he should have been aware of risks of cardiac surgery for that particular patient.

Naturally, the risk in making specific referrals extends far beyond the potential for lawsuits. It involves the health and welfare of the patient, the foremost concern of any dedicated doctor of chiropractic. Properly referring to a specific provider or specialty area requires a medical determination of a diagnosis of a non-chiropractic disease or condition.

Just as an M.D. is not competent to diagnose vertebral subluxation, a D.C. is not qualified to provide medical diagnoses. For the good of the patient, and to protect yourself against malpractice charges, it is best to provide patients with your report of unusual findings and allow them to make the determination as to how best to proceed, seeking whatever non-chiropractic medical or complementary care they feel is appropriate.

"Your liability if a referral doctor goofs," by Lee J. Johnson. Medical Economics, August 23, 1999.

"Will alternative-medicine referrals get you sued?" by Deborah Grandinetti. Medical Economics, May 24, 1999.

"Negligent Referral to Specialists," Risk Management Foundation, May 1999.