First Do No Harm

According to Dr. Mary Lynn Moran, knowing when to refer a patient can be as easy as remembering the Hippocratic Oath.

This is part 2 of a 2-part series.

Part 1: An Honest Consult: Knowing When to Refer

Associations like AACS and the American Academy of Facial Plastic and Reconstructive Surgery (AAFRPS) offer resources to discuss difficult cases and gain rapport with physicians in other specialties, so when it comes time to refer, a colleague can give guidance.

“One of the nice things about [AACS] is its collegiality,” Chris A. Lowery, D.O., AACS president 2019-2020, says. “The AACS is a multispecialty organization that includes board-certified physicians from multiple specialties including ENT, general surgery, dermatology, oculoplastics, plastic surgery, oral maxillofacial surgery, etc. Physician experience in the academy is widespread. If we don’t know a provider in our area to refer to, the AACS is often helpful in assisting us in finding a specialist in our area to refer a patient for a particular procedure.”

Most physicians, he says, are aware of their strengths and weaknesses and will refer accordingly, with additional help from AACS’s resources.

Mary Lynn Moran, M.D., president of AAFPRS, explains that there are also confidential Facebook pages for when physicians need help with challenging cases. She says, “[We] call colleagues — both within the specialty and outside of our subspecialty — when we are not sure about how to proceed with a patient.”

She adds that the AAFPRS and the American Board of Facial Plastic and Reconstructive Surgery (ABFPRS) Code of Ethics “binds physicians to the highest quality ethical care and prohibits in several instances placing any interest above that of the patient’s wellbeing.”

Both Dr.’s Moran and Waldman say that physicians taking stock of their competencies and being transparent with any treatment gaps is as easy as remembering the Hippocratic Oath.

“Referring a patient to another physician if you don’t think you are the best one to treat them is part of the ‘first do no harm’ oath that we all take as physicians,” Dr. Moran says. “The modern version of the Hippocratic Oath explicitly states, ‘I will not be ashamed to say, “I know not,” nor will I fail to call in my colleagues when the skills of another are needed for a patient’s recovery.’”

For those seeking to become more knowledgeable and learn new procedures out of their current scope of knowledge, Dr. Waldman says that there are ways to learn without putting patients in danger.

“There are videos that you can buy or purchase. I have a lot of visitors that come and see me do things… [You can] establish a relationship with [a] doctor or go to a live surgery course,” he says. “… observe firsthand at their office for a couple of days to see what the nuances of everything are, because you can't pick up everything from a lecture and slides.”

It’s not enough to go to a lecture or conference and then come back to the practice and immediately start offering the procedure to patients, he says.

“I have a slide at the end of a couple of my lectures [and] it says the most dangerous time for a patient is the first two weeks that a doctor returns from a conference,” he says, explaining that physicians can attend a lecture and want to immediately incorporate it into their practice.

“A 15-minute lecture is not going to get it done. I think you're endangering patients.”

Though there can be nuances in knowing when to refer a patient, three facts remain clear:

1. It’s important to take stock of your experience and expertise, then decide if you’re the best choice to provide care to a patient.

2. Never consider monetary gain when taking on cases.

3. Just because you can do a procedure, it doesn’t mean you should.