Many specialists believe that the best way to avoid litigation is to ignore all problems that are not part of their specialty. But many patients have multispecialty problems that require one physician to take overall responsibility for their care. This problem is exacerbated if the specialist is at the end of a long referral chain. In this situation, the specialist is prone to assume that someone else has ruled out all diagnoses other than those that would be appropriate to his or her special field of practice.

One case that settled prior to trial involved a woman in her mid-50s who presented to her physician with abdominal pain. Initial evaluation did not uncover an explanation, and she eventually sought care at a hospital emergency room. The emergency room physician did a general evaluation and wrote a differential diagnosis that included abdominal aortic aneurysm. She was admitted to the hospital under the care of a gynecologist and given an ultrasound and a pelvic examination. A mass was noted in her abdomen, and the pelvic examination discovered cervical cancer. She was then transferred to the regional cancer center for definitive treatment. Once in the cancer center on the gynecology service, she was treated for the cancer.

Over the next couple of weeks, she continued to complain of pain that was inappropriate for the extent of her cancer. Her treating physicians assumed that this pain was partially psychogenic, and they had her evaluated by a psychiatrist. The pain suddenly became much worse, and she was given a tranquilizer for anxiety. When she was finally examined three hours later, there was no blood supply to her legs; she had clotted off an abdominal aortic aneurysm. This diagnosis had been hinted at early in her evaluation, but once she was on a subspecialty gynecology cancer service, all diagnostic considerations were limited to gynecologic cancer and its complications.