To refer or not to refer?
When you and your patient disagree--an ethics case study
From the March 1995 ACP Observer, copyright © 1995 by the American College of Physicians.
- Previously published ethics case studies are available online.
- For additional ethics resources, visit the College's Center for Ethics and Professionalism
This is the 13th in a series of case studies with commentaries developed by the ACP Ethics and Human Rights Committee. The series elaborates on controversial or subtle aspects of issues not addressed in detail in the ACP "Ethics Manual" or other position statements.
Internist Linda Curtis has been caring for Jack Green, 48, and his wife, Betty, for two years, since the retirement of her partner, Dr. Smith. The Greens were Dr. Smith's patients for 18 years. Mr. Green is a small-business owner. He has never been seriously ill, but is seeing his wife through a long illness with cancer. He seems depressed at a routine cholesterol check but, despite Dr. Curtis' attempts, is unwilling to talk. He does say that he hasn't felt like himself lately, and complains of headaches, allergies, knee pain from an old jogging injury, and a rash on his face and elbows. "I need to feel better quick," he says, "I'd like to see a neurologist, orthopedic surgeon and dermatologist. Who do you recommend?"
"Slow down," responds Dr. Curtis. "Let's see if I can't help you first." Mr. Green gets upset. "I really want these problems resolved now--I can't afford to feel under the weather what with Betty sick. And I haven't been able to run very far lately." Running is Mr. Green's passion, and his primary exercise and stress relief.
After the exam, Dr. Curtis concludes that Mr. Green's problems do not warrant specialist intervention, not yet at least. She wonders how much of this is related to the pressure Mr. Green is under, and the physical demands of caring for his wife. She tries again to get him to talk, without success.
"OK. I'd like to start you on steroid cream for your psoriasis and Chlor-Trimeton for the allergies. The headaches are likely related to the allergies and to stress. Your joint is stable but I will talk to an orthopedic surgeon and determine whether a consultation is warranted. Let's see how it goes. I'd like you to come back next week." Dr. Curtis isn't convinced of the need for an orthopedist either, but feels pressured by Mr. Green's requests.
Dr. Curtis wants to talk further but the patient cuts her off. "If you won't get me the help I need, I'll have to get it myself." An unhappy Mr. Green leaves, but he does take his prescription and schedules a follow-up appointment.
Dr. Curtis talks to orthopedic surgeon Sam Jackson, who, after hearing the history and evaluation, concurs that Dr. Curtis is on the appropriate course. Dr. Curtis makes a note to herself to check Mr. Green's insurance coverage. She has just started participating in HealthE, an IPA-model HMO, and she is learning its procedures. If Mr. Green is with HealthE, he will need written referrals to specialists for that care to be covered.
Mr. Green returns for his follow-up visit. His symptoms are beginning to improve, but not enough to satisfy him. On further discussion he agrees that he doesn't really need to see a neurologist or dermatologist, but remains emphatic about wanting to see an orthopedist. "Where's Dr. Smith when I need him? He would have recommended specialists to me at the last visit," says Mr. Green.
It turns out Mr. Green is a fee-for-service patient, so no written referral is needed. But he mentions that as part of the yearly review of benefits at his company, he is considering switching coverage for his family and his employees to an HMO, perhaps HealthE. "Would you be referring me if I had different coverage?" he asks. He says he is going to call his insurer to complain. How should Dr. Curtis handle this?
When is a consultation warranted? The third edition of the ACP "Ethics Manual" states, "Physicians should obtain consultation when they feel a need for assistance in caring for the patient or when it is requested by the patient. ..." (1). Does this mean referrals should be made on demand? The short answer is no.
Referrals should be made when they are in the patient's best interest. Determining what is in the patient's best interest is a matter of professional judgment and medical indication. This applies regardless of patient pressure, peer or institutional pressures about the cost of care, what type of insurance the patient may have, or the physician's payment arrangement (1, 2). But with an insistent patient, this might be easier said than done.
"The welfare of the patient is always paramount in the consultation process," as it is in all aspects of the physician-patient relationship, states the "Ethics Manual" (1). The conflict here is in who is defining that welfare and how-the patient wants immediate intervention for what he sees as a problem requiring a specialist, while Dr. Curtis believes the issue for now is evaluation, which she is competent to handle. However, it is the physician who is in a position to determine what is medically indicated. This is the basis of managed care policies placing the primary care physician in the role of "gatekeeper," even though it may limit the patient's freedom of choice.
Indeed, all physicians have an obligation to use health resources appropriately and efficiently, avoiding unnecessary tests (including unjustified repetition of tests) and unnecessary consultations. First and foremost, the physician must be a patient advocate. But being a patient advocate does not necessarily mean doing everything the patient wants. And the traditional approach to patient advocacy is also being challenged by the need to be conscious of societal and institutional concerns about resource allocation (3).
Here Dr. Curtis sees no societal or institutional-patient conflict. She believes, and the orthopedic surgeon concurs, that she is on the right course in evaluating and following Mr. Green's knee condition. Dr. Curtis' greatest challenge is effectively communicating this to Mr. Green. Physician and patient must thoroughly discuss their concerns and expectations. Dr. Curtis may not be able to change Mr. Green's expectations (although she was successful regarding the dermatologist and neurologist), but she was right to try. She should continue to do so by informing the patient about her approach to care, the need to allow time for healing, and her discussion with Dr. Jackson.
Physicians should try to help patients develop realistic expectations about medical care. More care is not always better care, and tests carry risk and can result in false positives, increasing stress and leading to potential complications. Perhaps for the patient's previous physician, Dr. Smith, being a patient advocate meant doing what the patient wanted and doing more-though nearly 20 years ago there was less "more" to do.
The Greens are fee-for-service patients, which Dr. Curtis did not know at the time of her original recommendation. The payment arrangement was, correctly, not part of her thinking about a care plan for Mr. Green. Payment arrangements could be a subtle, or not so subtle, influence on clinical judgment. An HMO doctor could take a wait-and-see approach for too long: Under some contractual arrangements with HMOs, for example, physicians agree to a percentage withholding of their fees that is returned only if their referral account for specialist and laboratory services has a surplus at the end of the year. Often there are also bonuses for running a surplus. In the fee-for-service context, a physician could too quickly order, or repeat, a test or make a referral because of the financial incentive to do more and therefore be paid more (2,4,5).
Mr. Green has said he is considering changing coverage. Under the rules of HealthE, patients need a written referral from the primary care physician for care by a specialist to be covered. Dr. Curtis needs to discuss this with the patient, and encourage him to talk to HealthE about the details of coverage, so that he understands the rationale behind pre-authorized referrals and other terms of coverage. Such an understanding is essential if Mr. Green is to make an informed choice among insurance plans.
Mr. Green has also said that he will complain to his current insurer, which he is free to do. He may even start to talk about legal action. But the practice and documentation of medically appropriate care are the best defenses to challenges regarding that care, legal or otherwise. If after several weeks of conservative management Mr. Green is not better, or if there is evidence of a ligament injury or increased swelling, Dr. Curtis will want to rethink her position on referral. But for now, referral seems unnecessary and not beneficial to the patient.
It is likely that if Mr. Green remains adamant about seeing an orthopedist now, he will find one on his own. If on a subsequent visit Mr. Green persists in wanting names, Dr. Curtis should at that point give him some names of physicians she usually recommends. If he switches to HealthE, she should explain to Mr. Green that physician visits, tests and treatment without a referral would be at the patient's expense. Regardless of the insurance coverage, Dr. Curtis should indicate that she believes this is not medically indicated nor in Mr. Green's best interest at this time.
Acknowledgments: The Ethics and Human Rights Committee would like to thank Lois Snyder, JD, Ethics and Health Policy Counsel in ACP's Division of Health and Public Policy, author of this case study and commentary.
1. American College of Physicians. American College of Physicians Ethics Manual (third edition). Ann Intern Med. 1992; 117:947-60.
2. American College of Physicians. Ethics case study: When finances may influence physician decision-making. ACP Observer. 1990; 10:1,8-9,12.
3. Wolf SM. Health care reform and the future of physician ethics. Hastings Center Report. 1994; 24:28-41.
4. Hillman AL. Health maintenance organizations, financial incentives and physicians' judgments. Ann Intern Med. 1990; 112:891-3.
5. Rodwin MA. "Medicine, Money, and Morals: Physicians' Conflicts of Interest." New York; Oxford University Press, 1993.
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