Medical Ethics of Self-Referrals
November 15, 2010 12:43 PM   Subscribe

Medical Ethics question regarding physician at hospital referring patient to physician's own private practice.

My father-in-law had to be admitted to a psych ward at a local hospital after a serious psychotic break that culminated in a set of suicide attempts. He became intensely paranoid to the point where he wouldn't have conversations indoors, believing that security cameras might pick up on his conversations. He thought that every passing car was the FBI out to kill him, etc, etc. It's been fun.

After a week or so in a psych ward, he's stabilized and seems to be on his way to recovery. The improvement has been notable and we agreed with the nurses who believed that he was almost ready to be discharged. One of the conditions of discharge was the we set up appointments with a therapist to continue treatment (separate from his psychiatric care, which would continue).

All of these discussions took place with my wife, her brother, and myself. Based on these talks, we did a lot of research and found a great therapist in the region who specialized in people his age and was willing to take a new patient. This came upon a number of referrals from other therapists and from discussions with friends of ours in the industry.

During the discharge, which happened only with my mother-in-law present, the supervising Doctor told her that he had a private practice and would continue seeing him outside the hospital, and that in addition to being a psychiatrist, he was also a therapist. She then went and cancelled the appointment we had set up.

As with all family drama, there's a lot best left unsaid. What matter is that the mother-in-law is an immigrant with substantially reduced understanding of the American medical system, with little research capabilities, and has not truly understood how bad things got (she was out of the country when the break occurred and only returned once things were better).

There's little question in our minds that the supervising doctor steamrolled her a bit and saw a chance to make some money. When we talked with her, she seemed surprised that she may have done anything wrong, believing that the Doctor told her it was the right thing to do.

I'm not a vindictive person and I'm not asking this question in order to punish someone for treating an immigrant a poorly in order to make a questionable buck. Yet the supervising doctor is now the only doctor treating a family member. Before any confrontation, I'm curious whether this violates generally accepted medical ethics concerns over referrals or hospital privileges. A self-referral seems problematic, especially when other plans have been made.
posted by anonymous to Health & Fitness (9 answers total)
I'm pretty cynical, and also not a medical expert by any means. But this seems like one of the hallmarks of "continuity of care" as defined:

"Traditionally, continuity of care is idealized in the patient's experience of a 'continuous caring relationship' with an identified health care professional."

There is lots of sites outlining this concept such as Here
posted by Ad hominem at 12:51 PM on November 15, 2010

It seems reasonable to me *if* the doctor had already been treating your Father in Law successfully while he was hospitalized. Especially with somebody who is paranoid, I could see them having issues trusting new people.
posted by TooFewShoes at 12:52 PM on November 15, 2010

Nope, this is classic continuum of care. However, he and she have a right to see whomever they want.
posted by stormpooper at 12:55 PM on November 15, 2010

Stormpooper has it right. There is nothing wrong with this. The inpatient doctor may not have realized how much though you and your wife and her brother put into finding someone else for follow-up care. I'd bet that if you told him/her that you had already arranged follow-up care, he would've been just fine with it.

Now, self-referral is a problem with physicians have a vested financial interest in something outside of their primary role (e.g., seeing patients). For example, a psychiatrist with a financial stake in a medical imaging facility who refers all of his patients to that facility for brain MRIs (e.g., to rule out intracranial lesions) is committing a violation of the law under the Stark Law. But this ain't that. This is continuity of care.

Things get a little thornier for doctors like cardiologists, who are more procedure based, as discussed in this editorial.
posted by scblackman at 1:14 PM on November 15, 2010 [1 favorite]

In the acute care situation, it sometimes makes a lot of sense when a person has already established a relationship with one provider, and has started to feel comfortable, and has already explained the whole history, to just stick with that person when possible. It can be kind of re-traumatizing to tell the "what happened that brought you to my office today?" story over and over, and some people tend to be more sensitive to that experience. If you/your dad feels that the care this particular doctor offers doesn't meet your dad's needs, though, you're not bound to working with him, as others have said--it's more meant for ease-of-transition reasons, which can be particularly sort of important with a presentation like paranoia.
posted by so_gracefully at 2:06 PM on November 15, 2010

Did your mother-in-law mention that she had found another facility that she would prefer to use? That kind of makes a difference. Unless she explicitly stated she wished to go elsewhere and was talked out of it, I think it's a bit unfair to assume that a doctor who has been successfully treating a patient and wishes to continue doing so is simply seeing "a chance to make money." Is your father-in-law mentally in a place where he can voice his opinion? If so, maybe you could ask him what he would like?
posted by troublewithwolves at 2:26 PM on November 15, 2010

It's pretty standard for discharged patients to follow-up with the doctor who took care of them during the hospitalization. Like others have said, continuity of care is the principle at work here.

Did you communicate to the hospital your preferences for that particular therapist? Sometimes a preference like that get lost in the bureaucracy. You are not bound to see the hospital psychiatrist.
posted by Pantalaimon at 3:03 PM on November 15, 2010

I worked in a psych hospital, but am not giving you psychiatric advice or care. This is perfectly normal in the psych world (although the doc canceling the other Appt unexpectedly is a little weird). It's good for psychiatrists to continue with their inpatient clients aslong as the relationship is's all about continuity of care. Plus the doc already has the history so they don't have to start over.

However, that doesn't mean that the patient is required to continue with that doc. You can cancel that appointment as easily as the doc cancelled the other one. Bottom line...the patient has the choice of who to follow up with. He will need an MD psychiatrist to continue on meds anyway...could he see his inpatient doc for med checks and the other person for talk therapy? There's nothing unusual about that either, although keeping the two providers on the same treatment plan can be a challenge.
posted by MultiFaceted at 7:48 PM on November 15, 2010

My apologies...when I first read the question I thought it said the inpatient doc cancelled the other appointment. Disregard that part of my answer.
posted by MultiFaceted at 7:50 PM on November 15, 2010

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