Mr P, 42, was a nurse practitioner (NP) who worked with a primary care physician, Dr F, 60. Mr P had been working for the physician for the past 3 years, and the clinicians had a good working relationship. Dr F had particularly wanted to have a male NP, because she believed that some male patients were more comfortable talking to, or being examined by, another male, and she wanted to be able to offer that option. Dr F also employed a female NP.

Several of Mr P’s patients were referrals from existing patients of Dr F. One such referral was Mr D, a 51-year-old truck driver who had been referred by his wife, a current patient of Dr F’s. Mr D’s wife made an appointment for her husband after he began experiencing bleeding during bowel movements and rectal pain. 

The patient seemed uncomfortable discussing his problem, but he reported that he had been bleeding intermittently during bowel movements for the past 2 months. When pressed, he told Mr P that the blood was bright red, and that at times it seemed like the toilet was full of blood.

After their discussion, Mr P informed the patient that he would now perform a physical exam, including a digital rectal examination. 

The digital exam was negative for any tumors or tears, and Mr P diagnosed the patient with bleeding due to internal hemorrhoids. 

“I would advise you to schedule a colonoscopy to rule out anything else,” said the clinician. “I can give you a referral to a gastroenterologist who is on your plan.”

The patient adamantly refused any referral and told the clinician that he was not interested in a colonoscopy. Mr P gave him a prescription for suppositories and a hemorrhoid cream, and then scheduled the patient to return in 3 weeks for a follow-up appointment.

After the patient left, Mr P documented the visit, the exam, and the diagnosis, but he neglected to note that he had advised the patient to get a colonoscopy and that the patient had refused.

At the follow-up exam, the patient reported that the rectal pain and bleeding had ceased and that he had not noticed any blood in his stools. Mr P did not suggest a colonoscopy again.

During the next year and a half, Mr P saw the patient 8 more times for various other complaints and minor illnesses. The patient never relayed any concerns about continued rectal pain and bleeding, and Mr P did not ask, nor did he have any further discussions with the patient, regarding a colonoscopy.

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