Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, August 13, 2007

Ethical Dilemma: Doctors as Patients

I got a phone call from a doctor I've covered for from time to time. He had a favor to ask me: would I write a referral for an MRI for him?

Actually, he had his office staff call my staff. I asked to speak to him directly.

It turns out the MRI was a perfectly appropriate follow-up for a questionable CT finding. Usually he writes all his own referrals, but for some reason in this case, the facility was refusing to accept the referral from his office, even though the insurance company had no objections. As it happened, his insurance was a capitated plan. He'd have to switch to my office as a patient; I'd receive capitation payments for him, but then again all his referrals would count towards my utilization figures.

I thought about what I should do.

It's a well-documented fact that many doctors -- especially those in primary care -- do not have a personal physician. They do what this guy does: take care of things themselves. It's also pretty clear that this is not a good idea.

So I offered as tactfully as I could to see him in my office, mainly to have a chart on him so we could document results of tests as well as referrals (in case the HMO came a-calling), but also to serve as his personal physician.

He declined.

He went on for awhile in such a way as to imply that what he was asking wasn't such a big deal and that he thought I was making more of a fuss over it than I should. He'd once needed an MRI of his knee, and a mutual orthopedist friend had written the script without a second thought. He ended the conversation by saying that he'd call around and see if he could find someone else willing to help him out, and would get back to me.

I found myself reflecting on the interaction.

What if the roles were reversed? Certainly I've written myself orders for routine screening tests. I even have a "chart" for myself in my office to keep track of labs and immunizations and other things. I occasionally go see a doctor -- usually a specialist -- for specific acute problems, but I must confess that I do not have a personal physician. However if I found myself in the position of needing a primary physician for administrative purposes, and if that physician were to gently indicate that he (and I, for that matter) wouldn't do what I was asking for a patient without a visit, I would probably sigh, admit to myself that he was right, and go see him as an actual patient.

It bothered me that this guy didn't seem to get it. It's just paperwork for a stupid insurance company. Can't I do a favor for a colleague?

Well let's see. I frequently get calls from neighbors and friends looking for "favors." Sometimes they don't have a doctor; other times they just don't want to bother theirs. (I usually manage to ignore the insult implied by the fact that they're willing to bother me.) I've learned to say no to these requests. Without a doctor-patient relationship -- which includes a visit, an exam and a chart -- I won't sign, order or prescribe anything. It's bad medicine, and -- oh yeah! -- illegal.

So why is it any different when it's a doctor/colleague?

I decided that it wasn't.

Tell me if -- and how -- I'm wrong.

24 Comments:

At Sun Aug 12, 06:15:00 PM, Anonymous Anonymous said...

I think you are wrong, in this case, because it is a diagnostic test.

 
At Sun Aug 12, 06:27:00 PM, Blogger #1 Dinosaur said...

Anon: As the ordering physician, am I not responsible for dealing with the results of the test? How can I do that without a history and physical?

 
At Sun Aug 12, 06:27:00 PM, Anonymous Anonymous said...

Well, why should we help each other at all then...

 
At Sun Aug 12, 07:14:00 PM, Anonymous Anonymous said...

Not that I've never treated myself (patanol out of the drug cupboard, etc.) but I just think it's a bad idea in general. Much as I think I can be objective about my own health problems, I am not always (recent foot problem turned me into a crazy woman). Plus, I cannot do Pap smears, etc. on myself. It was easy at my old job--my female doc and I saw each other. Now I moved and I don't do primary care, so I had to pick someone in my new town. Got the dirt on him from one of my former partners who had worked with him before (she was my patient, too). Decided I had grown up enough to have a male doctor, being he was highly recommended and I didn't know anything about the women. He's been really great--despite me crying in his office (twice) about my foot issue. I think it's really hard to take care of other doctors--very anxiety-provoking for the doctor and doctor-patient. I know I'm hypervigilant about not bugging my doctor for referrals, etc. without visits. It's also kind of embarassing sometimes to admit what you might perceive as shortcomings in yourself (like being freakishly upset about a sore foot) to a colleague. But, I think it's good to be a patient once in awhile--I think it's easy for us to remember what it's like to be on the patient side of the doctor-patient relationship.

 
At Sun Aug 12, 07:28:00 PM, Anonymous Anonymous said...

Well, it's clearly different because neighbors and friends are not licensed to practice medicine and thus, presumably capable of managing their own health (how well they may do this is another matter). Like any other professional courtesy, you certainly aren't obliged to do it. In this case I actually tend to agree with you because a referral for a multi-thousand dollar imaging test goes a bit beyond the standard, though I don't really understand why he could get an initial CT from someone and yet not the MRI (CT in the ED?).

 
At Sun Aug 12, 07:58:00 PM, Blogger Pieces of Mind said...

I think you are in the right, from an ethical, medical and legal standpoint.

I'm not surprised your colleague doesn't want to come in. We all feel vulnerable as patients.

But someone needs to be coordinating his care. Even if his MRI results are fine this one time, at some point I can guarantee he will need a personal physician, and it's better to establish a relationship now than when there's a crisis.

 
At Sun Aug 12, 08:23:00 PM, Blogger Rob said...

Dino:
I am 100% in you camp on this one (no big surprise). I feel that treating yourself is a dangerous thing to do. You have no objectivity and you don't necessarily see things right. I do require other docs to come to the office. Now if they can't do it, I at least expect a phone call to run things by me if they are ordering a test. Since I am the PCP, I will be responsible for many of the results, and I should know the thought process that led to ordering the test in the first place.

We require our office staff to make appointments and be seen. We also do the same with family members of physicians in our group, and other physicians as well, if at all possible (although it is hard not to "curbside" to save time). The whole process of taking a good history is essential to getting to the right diagnosis and not missing more subtle things. Why should other doctors get worse care just because they are doctors?

 
At Sun Aug 12, 10:07:00 PM, Blogger Lynn Price said...

Geez, Dino, it's your legal and ethical neck on the chopping block, so I say you should do what you feel comfortable doing. If that's hauling his ungrateful arse in for a check-up, then that's what it should be. He's a mongrel for suggesting otherwise.

Now, I have this boil on my butt and wondered if you could look at it for me after you get off work...

 
At Sun Aug 12, 10:24:00 PM, Blogger TBTAM said...

#1-
I totally agree with you. I think one of the best things we can do for our colleagues is to treat them like patients.

 
At Sun Aug 12, 11:14:00 PM, Anonymous EJ said...

You were textbook ethical, but you were wrong.

You see, what you refused is called basic professional courtesy. Why? Because "It turns out the MRI was a perfectly appropriate follow-up for a questionable CT finding." So you had the perfect reason for ordering an MRI, even without consulting him. Plus imagine that all that the guy wants is to get that lesion out of his head and his life, by getting an MRI ASAP. Try walking in his shoes, living with an abnormal CT finding.

If that MRI had confirmed something pathological, THEN you could have discussed starting a real physician-patient relationship, or ending the one that existed only on paper.

Now, I see absolutely no reason for refusing the referral, except for being "more Catholic than the Pope". With all due and very sincere respect.

 
At Sun Aug 12, 11:15:00 PM, Anonymous EJ said...

Sorry, I meant to say "So you had the perfect reason for ordering an MRI, even without EXAMINING him."

 
At Sun Aug 12, 11:37:00 PM, Blogger Rob said...

No, the doc should have called you first to explain the ordering of the test. THAT is basic courtesy.

 
At Mon Aug 13, 03:08:00 AM, Blogger Alijor said...

For a diagnostic test, I wouldn't worry about it.

I don't know if it's a question of ethics, really, but a question of trust. Ethically, it would come down to a question if you were receiving payments or something. This is different- I think that doctor's reaction might have been something like, "oh, you don't trust my opinion?" which he either took personally, or as a member of a medical community ("doctors should trust other doctors"). But it's probably neither of those- "ej's" probably right, he was just nervous about the MRI or something.

Either way, it's whatever YOU feel like doing, you don't have to justify it or say it's right or wrong.

If another doctor thinks it's ok, that's fine, it doesn't mean you're wrong. And if think you made the right decision, that doesn't make another doctor who would do it wrong either.

No one should think you "ought to" or "ought not to" give a referall to this doctor. That's totally up to your comfort level. Just a thought.

Cheers,
Alijor

 
At Mon Aug 13, 04:25:00 AM, Blogger Elaine said...

I think you would have been very foolish to make any referral without at least excamining him. His lack of trust in your judgement means that you were definitely correct. What would he have done if the MRI had shown something suspicious? And then where would you have been?

 
At Mon Aug 13, 06:54:00 AM, Blogger MedStudentGod (MSG) said...

Dino,

Carried out with the professionalism that I have come to expect from you. Well done. I'm glad to see that you're willing to set limits, even when it's someone that you've done some business with.

 
At Mon Aug 13, 11:58:00 AM, Blogger rlbates said...

I agree with you. What's he going to do when the results come back? I actually want my "friend/doc" to check me and make sure I'm not missing something, especially when it's a problem big enough to warrant an MRI.

 
At Mon Aug 13, 04:10:00 PM, Anonymous tom said...

Courtesy?? His office staff call your office and ask for some "courtesy!" He can't call you?? Then when you call him, he implies its no big deal -for who?

What other corners does he cut in his practice.

What if the MRI comes back Grade 4 Glio- and he elects to do nothing, tell no one and just die. Where does that choice get documented and what would your liability be
if the surviving spouse decides that had he really understood the situation (your fault that he did not)he would be alive today. So...., that life insurance that was never enough anyway now stands a good chance of being augmented by a very nice lawsuit against you???
No good deed goes unpunished- you did the right thing-

 
At Mon Aug 13, 07:23:00 PM, Blogger Dr. Smak said...

Dr. Dino,

One of the many situations where the easy answer is not the best answer. I agree with tom's point - by assuming any level of care you assume some degree of medicolegal liability. How far a lawyer could take that depends on how 'good' the lawyer is. When he dies of colon CA in 5 years having never had a colonoscopy, would that be your fault? After all, you're getting those capitated payments...

I also agree with Tom's first point: it was the epitome of rudeness not to speak to you in person. Geesh.

 
At Mon Aug 13, 08:10:00 PM, Blogger #1 Dinosaur said...

Many thanks for all the feedback. One of the real problems with solo practice is the lack of availability for just this kind of reality check. Nice to know the general consensus is that I read the situation correctly.

Next issue is this: how to deal with this person who "doesn't get it", encompassing both the courtesy thing (I tend to have a very thick skin, so sometimes it takes awhile for me to realize when I'm being insulted) and the issue of self-treatment. I tried explaining it and it didn't take. Any other suggestions?

I have patients like this who also just don't get it. Ultimately, there's not much I can do. Do I give up on the colleague as well?

Also, how much of a complication does it introduce if I really need him to cover for me, and am therefore motivated to stay in his good graces?

 
At Mon Aug 13, 11:33:00 PM, Blogger local MD said...

I believe someone once said, "The physician who treats himself has a fool for a patient."

 
At Tue Aug 14, 12:53:00 PM, Anonymous tom said...

Dino, if getting someone to cover for you means you will be expected (required?) to do things that compromise your persona;/professional values, seek other call coverage.

If you have no other coverage options, I would take the guy to lunch and discuss your concerns. If he can not be swayed to respect your philosophy of patient care-I would not trust him to care for my patients.

That may mean that you need to recruit an associate, but I would guess youalready have a plan for that!

 
At Wed Aug 15, 09:32:00 AM, Anonymous difficultpt said...

I agree with Tom--why would you want this guy to cover for you?

 
At Wed Aug 15, 06:13:00 PM, Blogger Doc said...

Ethically and medically, you must start a chart and document what you do. I have helped out friends before, but almost always open a chart and jot down what's been done. It's difficult, but necessary. I generally tell people that in order to ensure the best care, I need to write things down.
Also there is the CYA aspect of it.

 
At Thu Aug 16, 03:00:00 AM, Blogger SeaSpray said...

I agree with you and I wonder how he would have felt if the roles were reversed?

 

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