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.