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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 PPO or HMO 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 upon the patient's greater reliance upon 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 a serious sinus infection, but the obstetrician is unable to find a specialist willing to see the patient. In this situation, the obstetrician would be obligated to treat the infection, despite its being outside his or her chosen area of expertise.

The more difficult problem is the patient who develops a condition that the specialist cannot treat alone but the management of which is part of his or her specialty--for example, a gastroenterologist who finds that the patient has an acute appendicitis. The physician cannot perform the surgery, but it would be unacceptable to try to treat the patient without surgery. The gastroenterologist must be able to arrange proper surgical referrals as part of his or her duty to the patient. The patient is entitled to assume that the specialist is prepared to coordinate all of the personnel necessary to treat the patient's gastrointestinal problems. This expectation of comprehensive services will be discussed in the chapters that deal with specific specialties; it is a growing problem as traditional care patterns are fragmented.

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