Sunday, September 07, 2008

Another Thing to Ponder

Thanks for the lively discussion in the post below. If you missed it, Click Here.

So Gerbil tells us she never refers patients to therapists she doesn't know personally.

This got me thinking: How much responsibility does a referring doctor bear for the treatment of his patient by another doctor, one he's referred the patient to?

Okay, so in this wide world of psychiatry, when a patient asks me for a referral (gay/straight/Republican/dog-owner, whatever), I often give names of psychiatrists I know personally whom I trust. In this realm, I'm pro-Gerbil. If someone wants a referral for someone in their insurance network, I tell them to call the insurance company: I have no idea who is in what networks. And sometimes I can even give people the name of a good primary care doctor (one I know and think highly of). If they go, and if the doc does wrong by them, how much am I held responsible for this? Most readers seem to feel it's not cool to "out" a gay doc, but am I obligated to tell a patient that someone I'm referring him to has been the subject of a malpractice suit? Or 5 malpractice suits? Or that decades ago he's been sanctioned by a professional board or banned from a hospital? Or that I happen to know he's cheated on his wife? If I don't just happen to know it (via the grapevine or whatever), am I obligated to research the past of another physician before I give out a name? Am I more obligated to do the Googling than the patient is?

So you say Why Would I Refer anyone to someone with an unseemly background? And actually, I wouldn't if I knew the doctor had these issues and if there were other choices. But what if one lives in a small town and the patient needs a specialist, and there is only one such specialist (...oh, say a retinal surgeon or a hand specialist... or a cosmetic surgeon who specializes your body part) and that specialist is known to be competent despite his unsavory past.

I know, I know...therapists are different.

Chime in:


Anonymous said...

I take it chapter 191 of your book will be: things to ponder

Novalis said...

Unless or until some kind of published performance standards are agreed upon for psychiatrists and therapists (unlikely to happen any time soon since it has been problematic to do so even for hospitals or cardiologists who in many ways have a much more straightforward mission), all one has to go on in evaluating other professionals is essentially word of mouth (often from patients themselves of course).

So all I tell patients is that "I've heard good things" about someone's practice, but that I cannot guarantee anything ("results may vary," as the drug ads say). Otherwise I would share only those things about the other professional in question that were already accessible through a public record.

Anonymous said...

Yikes! I agree with Novalis... if you have unflattering, private second-hand information about someone, better not to share it--especially with patients. Otherwise, you open yourself to a reputation for gossip, or worse, a lawsuit for slander. We do sometimes repeat what "Dr. So-and-so" said about "Dr. You-Know-Who"; in which case, the dispersal of information may end up reflecting badly on both parties.

I hope you wouldn't refer a patient to someone you'd be reluctant to see yourself. If that means demurring when asked for a recommendation, or referring to someone out of town (if you live somewhere small), so be it.

If a physician is competent to handle my medical problems, personally I couldn't care less what kind of mess he/she's made of his/her personal life. If the physician is professionally incompetent or unethical, then please don't send me there!

If my pdoc had referred me to the troubled therapist I've been seeing, I wouldn't blame him for the situation, but you can believe I'd let him know about it.

Dr. Pink Freud said...

Caveat emptor. Preface the referral with what you do (or don't know). It's the potential patient's responsibility to do the research, and ultimately, after meeting the doc, decide if it's a good fit. As far as lawsuits, or complaints, if you stay in this field for any length of time, you're going to get sued (consider our litigious society; everyone is out for a quick buck), or accumulate a few complaints. Hey, not every doc is a good fit for every patient.

Anonymous said...

I don't hold any animosity toward the GP who referred me to my previous psychiatrist. I know that had he known that my shrink had multiple arrests (which my shrink didn't report to the state Board) & that my shrink had problems keeping his hands to himself he would have referred me elsewhere. Later, my GP apologized to me for the referral, but it was not necessary. The shrink was a likeable guy & it's easy to see how people could get conned. I'm sure we weren't the only ones conned by this guy.

Gerbil said...

When I was working for insurance, people would call for names of therapists or psychiatrists in their area and then ask me how they were supposed to choose from among these providers. I'd say something generic about personality fit, schedules, and so forth--and about one-third of callers would ask me whom I would recommend. And in all but one case (when one of the hits was my own therapist, for whom my feelings were rather tepid) I could honesly say that I didn't know any of them, and even if I did I wouldn't be permitted to make a personal recommendation anyway. (In that one case, the caller thankfully didn't ask for my opinion!)

One of my professors, in our Professional Ethics course, told us that when we (as psychologists) provide a referral, we are tacitly saying "I trust this person and his/her competence to treat you." He went on to say that it's better to provide three names than just one--because this not only empowers the client with choice, but it also says that there isn't just one person who can help (and if that person is unavailable, you are SOL).

I wouldn't recommend a hairdresser whose work I didn't know firsthand. The stakes are even higher with mental health providers.

Esther said...

Give the reference and caution the patient to do his or her own research. Really, a referral is just a suggestion. I have had referrals and I take them for what they are. I then look up the doctor I was referred to and decide if it makes sense to go there.

I really don't think it's necessary to tell a patient about another doctor's personal life etc. That's the other doctor's business. I mean, as long as the other doctor is still in practice and hasn't committed a crime.

shraddha said...

Huge dilemma.
Its a very valid point to ponder.


Anonymous said...

As a patient I hope for a little better quality of referral when it comes from a doctor than when it comes from a friend but I don't expect perfection either. I'd rather have NO referral and hunt myself than to be pointed towards somebody who has been kicked off a hospital staff and has multiple malpractice issues. I agree that if you would not go to the doctor then I don't want to be sent there either.

In the end I let my opinion rule so I do not hold the reference provider responsible. My General Practitioner sent me to both an endocrinologist and an orthopedist that I thought were less than high quality providers. My current endocrinologist was referred by a friend and that doctor referred the best GYN I have ever had who in turn sent me to a great colonoscopy doc and a great hand specialist when I needed hand surgery. I ask contractors for other contractor referrals, too, and usually have reasonably good though often more expensive providers.