Communication is extremely important, particularly in the field of medicine, and especially when more than one clinician is treating a patient. This month’s case involves a referral to another physician, – a situation where it is imperative that the referring physician provide all vital information about the patient’s condition to the one who is getting the referral. It is, however, equally important for the clinician getting the referral to do more than simply rely on the note from the referring physician.

In this case, the referring physician was Dr P, a psychiatrist. He had been treating the patient, Ms W, 38, for about a decade following two suicide attempts in her late 20’s. Ms W was being treated for depression, and was taking lorazepam and citalopram. For several months, Ms W had been complaining to Dr P about sleep issues, including difficulty sleeping and restless legs syndrome.

Dr P explained that this was not his field of expertise, but that he would refer her to a colleague who was an internal medicine sleep specialist. He wrote out a referral for Ms W to see Dr S, the specialist, and sent Dr S a brief summary of the issue including that Ms W was being treated for depression. However, Dr P left out the information about the suicide attempts.

Ms W met with Dr S, who discussed her sleep issues with her, noted her history of depression, but did not do any assessment of self-harm. Dr S advised the patient that the first thing to do was a sleep study. The sleep study revealed that Ms W had sleep apnea. Dr S recommended a Bilevel Positive Airway Pressure (BiPap) machine for the sleep apnea, and prescribed pramipexole for the restless legs syndrome. For the next two months, Ms W and Dr S communicated weekly via email to discuss the effectiveness of the treatment. It became clear during this period, that the medication prescribed for restless legs syndrome was not helping.

The patient returned to see Dr S after two months. Dr S told the patient to discontinue the pramipexole, since it did not seem to be helping, and instead prescribed a low (5mg) dose of oxycodone. She gave the patient a prescription for 60 pills. This time the treatment seemed to work, and the patient reported getting relief. Six weeks later, Dr S wrote a prescription for another 200 oxycodone pills, but other than the prescription, she made no notes in the chart.