To the Editor:

The article “Seven Reasons Family Doctors Get Sued and How to Reduce Your Risk” by Dr. Richard Roberts [March 2003, page 29] included useful information. However, waiting to consult until after three visits “because it’s as good a number as any” is an invitation to disaster. Uncertainty is integral to primary care and must always trigger an assessment of risk in order to determine how urgently a diagnosis must be pursued. I have recently been consulted about two malpractice cases in which immediate consultation would likely have avoided horrendous outcomes.

Author’s response:

Even an astute clinician concludes a number of patient visits with only a tentative or working diagnosis and a request that the patient return after additional time, further testing or empiric therapy, following which a more definitive diagnosis can be determined. Of course there are situations where immediate consultation is warranted. Conversely, consultations that are made too hastily also raise liability risk for negligent referral, given their cascade of potentially harmful effects (e.g., unnecessary surgery that goes awry). Every day we must make clinical judgments about the urgency of a problem. My point in offering the “rule of three” was to urge clinicians to set a threshold for themselves and consider consultation, if only with their practice partner, for patients with nonurgent problems that continue to be a diagnostic dilemma after several visits.