Sunday, August 9, 2009

Medical Ethics –vs- Medical Politics: What Patients Should Know


Medical politics has dominated the news for months. Each day, we read about the machinations of various congressional committees and our legislators who are dueling over health care reform. We learn about deals that the president has forged with various medical industry stakeholders. We watch as many liberal Democrats angle to put the ‘Blue Dogs’ in a secure kennel. We read about town hall meetings across the country being disrupted by folks who are accused of being right wing tools. Too much politics and too little policy.

There is another genre of medical politics that is not covered by the press, but should be of interest to every one of us who seeks health care. This is the politics that exists in every doctor’s office and directly affects your medical care. I was never taught about any of this during my medical training. I learned about it on the job, and much of it isn’t pretty.

As a younger doctor, I assumed that physicians chose consultants for their patients based on their medical skill. In other words, if my doctor sent me to a cardiologist, it meant that my physician believed that this specialist was the best available within a reasonable driving distance. While nearly all physicians I work with today choose competent specialty consultants, there are many other invisible influences present that affect these referrals, none of which are known to the patient.
The fundmental operative rule is that a doctor refers to a colleague who refers back to him, particulary in medical private practices. This is acceptable, provided that both physicians are highly qualified practitioners. However, if a questionable gastroenterologist refers heavily to an excellent surgeon, should the surgeon refer back to him if there are more qualified gastroenterologists available? Should the surgeon risk an important referral source by not reciprocating? I know what the ideal answer should be, but these conflicts may not be so cleanly resolved in the real world.

Another force influencing referral behavior is the physician’s practice type. For example, employed physicians, particularly in large medical groups and teaching institutions, are strongly ‘encouraged’ to refer within their own group. I’ve been there. Conversely, private pracitioners tend to refer to other private physicians to support this practice model, which is increasingly under threat.

We physicians feel that we are uncorruptible. None of us believes (or will admit) that we can be bought or unduely influenced. Yet, many doctors entertain colleagues at social gatherings, country clubs and sporting events, not so much for their stimulating company, but more to cultivate personal relationships to keep the referral pipeline well lubricated. I’ve never done this, but I’ve seen this tactic from a distance, and it works. This is the primary strategy of pharmaceutical representatives who, until the practice was curtailed, gave doctors free food, honorariums and assorted labled office trinkets. Such largesse, from a drug company or a doctor, generates a subtle feeling of obligation on the recipient.

In my own gastroenterology practice, there are physicians who consult me in one hospital, but not in another where the internal politics are different. For many years, this differential treatment by consulting physicians vexed me, but I have come to accept it as a reality that I cannot change.

I am not immune to these forces and admit that various considerations enter my mind when I am choosing specialists for a patients.. So, I am both a victim and a perpetrator of medical politics.

I don’t think that any of this is evil. In most instances, patients still receive competent medical care. The public, however, should be aware that their doctors may be weighing concerns unrelated to their health. Patients have a clear right to ask their doctors directly why they have selected a certain specialist over others, and they deserve a response.

Tip O’Neill, the former Speaker of the House is credited with coining the adage, all politics is local’. He wasn’t referring to the medical profession, but I think his maxim fits us quite well.

8 comments:

Dave McNeil, M.D. said...

Michael -
Interesting. Much seems accurate. I have been blessed in that I have been busy enough not to care if a specialist to whom I make a referral will refer back. Funny thing then happens: If I make the right referral and the referred patient gets excellent care, THE PATIENT often makes a subsequent referral - or several - to me. Is it a way of saying thanks? Or are they primarily interested in securing the same quality of care for friends and family?

I have been cut out of relationships because I myself do not always refer back. And one time I all-but-ceased referring to an excellent specialist after having referred dozens to him: He never referred back and never communicated about the patients I sent him. But I still will send someone his way if I think what he offers will make a substantial difference in patient outcome.

I used to participate in social functions, witnessed the favor culling, never got any referrals out of it myself, and stopped going years ago. Haven't missed them.

Michael Kirsch, M.D. said...

Appreciate you comments. Think of all the free dinners we're missing!

Anonymous said...

Splendid entry this week. Have you considered publishing your articles in a book? It should sell well.

Your advise though is not practical. Suppose that a patient asks a doctor why he is referring him to a specialist X, or giving a choice between X, Y, and Z. Even if the doctor is making the referal for other than purely medical reasons, would not he be able to hide that? Would not the doctor feel that the patient is suspecting unfair play? Would not that undermine the trust required in the relationship? I do not feel comfortable asking such questions because it puts both me and the doctor in an awkard position and I will not get the information I'm looking for anyway. Yes, it would be nice to get a truthful answer, just as it would be nice to cut healthcare expenses by half and eliminate tort abuse.

Anonymous said...

The real problem here is the monopoly the doctors use to keep their incomes high, by restricting the number of medical schools. See here for more shocking evidence.

http://wallstreetpit.com/5769-the-medical-cartel-why-are-md-salaries-so-high

Its time to take on the USA's most powerful union!!

Anonymous said...

This discussion is very valuable. I am a DES daughter who lives in fear of being shut out by physicians who refer me to each other as an empty gesture when neither wants to give my case more than a superficial look, because I have unusual DES effects that they've never seen. Great! What I have told doctors about this or that not being right eventually has been validated despite prolonged skepticism; unfortunately the validation usually comes under the knife or a scope because my issues don't show up on blood tests, and they're hard to define with imaging.

I'm not an effing idiot. Nor did I bring this situation on myself. Any suggestions as to how I, and other patients in unusual circumstances, can get past these pretend referrals and go right to effective, interested, committed care?

Thanks.

Michael Kirsch, M.D. said...

I am familiar with your conundrum. The key to solving such a dilemma is to have a primary care physician you trust who can serve as your vigorous advocate. This is one of your best protections against uncoordinated and unnecessary care. As you suggest, patients themselves have to advocate for themselves. Ask questions and be a little skeptical. Physicians advise as best we can, but patients should be making the decisions that affect them directly.

Anonymous said...

Thank you, I appreciate that. I have a family physician who I think is committed to his patients. So far there's been one referral to a specialist, who is quite thorough. Hopefully I can get some clear answers, which hopefully will help inform other patients' and doctors' experiences.

Alertness certainly is good -- it's one of the pillars of preventive medicine -- but when a doctor doesn't really take in what an alert patient is saying, often for lack of a precedent in his/her body of knowledge but sometimes for sheer lack of interest, the patient is left in limbo.

I've had several referrals that started from square one with my profile. Fine to keep it simple, but unfortunately there just ain't anything simple about DES.

monty said...
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