Introduction

In the correspondence section of this issue Dr. Thomas George contests our expressed view that it is unethical for a doctor to take over a patient already under the care of another doctor without a note of referral.

The basis for this view is the doctor-patient relationship which has, hitherto, been held inviolable. We review this concept and return to another point raised by Dr. George.

The relationship

“There is a common belief among the public that a medical practitioner is at the beck and call of anyone who chooses to send for him, but it must be remembered that there is no law to compel a medical practitioner to attend a patient except in a case where he has previously bound himself by contractual obligations or has already undertaken the treatment.” (1)

A contractual doctor-patient relationship is established when the patient makes a request for medical examination, diagnosis, opinion, advice or treatment and the doctor undertakes to provide these. (There are situations when a request by the patient is not necessary. Treatment of an infant – where the parents make the request – or that of a comatose victim of an accident are examples.) The sanctity of such a relationship safe. guards the interest of the patient, the doctor assuming all responsibility for providing health care.

The patient has every right to terminate a relationship with his doctor at any time and seek the help of another. A reciprocal right rests with the doctor. The formal relationship may be brought to an end when the patient gives notice of intent to terminate it or when the doctor withdraws his undertaking. In the latter event, the doctor is duty bound to continue to offer all possible help to the patient till the patient establishes a formal relationship with another doctor. The General Medical Council of Great Britain upholds the right of doctors to refuse to accept individual patients when a satisfactory relationship between the doctor and patient does not exist for want of committment on either side (2).

A doctor can, at any time, request the help of a colleague or specialist in the best interests of his patient. Such a request must be specific and made in writing, all relevant medical details being provided to the other doctor. In an emergency, the request may be made and details provided orally on the understanding that as soon as time permits, a written note will follow. This step precludes any the consultant misunderstanding of intention or fact by the consultant.

The consultant, in turn, is duty-bound to return the patient to the referring doctor with a note bearing details of facts elicited, diagnosis made and treatment advised.

Ethical norms have traditionally discouraged shopping for opinions or therapy. Such a practice destroys the doctor-patient relationship established with the primary physician.

Thus arose the practice of not seeing a patient already under the care of another doctor without a specific referral.

Second opinion

The patient, in doubt despite detailed explanation by his doctor of the nature of his illness and treatment advocated, can ask for a second medical opinion.

Medical ethics demands acquiescence based on the patient’s right to such counsel. The doctor is obliged to write a referral note and provide all relevant details. If the doctor disagrees with the patient’s choice of consultant for second opinion he is justified in terminating his relationship with the patient after writing the note of referral.

Consequences of disregard ,for the relationship

The obvious consequence is a free-for-all among doctors, with no holds barred, in the struggle to gain more patients. If I can cheerfully take over the investigation and treatment of a patient known to be under the care of another neurosurgeon, it is only a matter of time before I extend my grappling hook in the form of a tout or agent who will divert to me patients intending to see another neurosurgeon. Subtler and more vicious forms include linkages with pathology laboratories, imaging centres and others where, for a consideration, my ‘virtues’ are extolled before patients needing neurosurgery and the reputation of the consultant already in charge tarnished.

Lest this appear fanciful, let me assure you that such practices are not rare in the metropolitan centres.

Another consequence is the already common practice of shopping for opinions. The well-to-do patient moves from doctor to doctor, clinic to hospital, amassing a stack of documents which, at times, contain conflicting views and suggestions. Often, the new consultant orders repetition of tests that have just been performed, at another specified centre, for non-scientific reasons. Patients are also deflected to practitioners of alternative systems of health care and even to charlatans and quacks. Patient and family end up in total confusion, unable to choose between the many options offered. By trusting no one, they have destroyed the basis of faith. It is not uncommon for the patient to spend huge sums without receiving any relevant or effective care and when the illness has worsened to a critical state, be sent off to a public teaching hospital ‘for further management’. Just as too many cooks spoil the broth, multiple medical opinions breed confusion and harm the patient’s interest.

Dissolution of the doctor-patient relationship also brings in its wake a major legal handicap. Since the patient is consulting more than one expert, each of whom is in ignorance of what the other is doing, no one will accept responsibility in the event of a mishap. The safety net provided by the official system of referral and transfer of medical information in writing in both directions between general practitioner and consultant or consultant and consultant is now missing.

Worst of all, disregard for the relationship destroys the traditional bond of affection between family and general practitioner. The general practitioner is considered a member of the family by many. His counsel and advice are sought on all matters pertaining to health and sickness. The services of a consultant are sought on his recommendation and further treatment is based on the advice offered jointly by him and the consultant. The linkages provided by the system of referral gives the patient a fixed source of trusted counsel – the family doctor.

What if a doctor refuses to refer the patient?

Dr. George rightly asks, ‘How many doctors, either in the private or public sector, will actually refer patients to another in their own specialty?’ Given the prevalent atmosphere, the reluctance to part with a patient who represents a source of considerable income is not surprising.

The solution has been long established. The patient is free to break his relationship with the doctor concerned and establish a relationship with another. In doing so, he will cut off all connections with the former.

The situation gets somewhat complex when the patient has already undergone major surgery at the hands of a consultant who now refuses to refer him to another for a second opinion. Terminating the relationship may deprive the patient of all data pertaining to the earlier operation. (Few surgeons provide their patients a copy of the detailed operation note. Many surgeons retain vital reports, xray and scan films.)

Under such circumstances, when I am approached by a patient to provide a second opinion, I write to the earlier surgeon explaining the circumstances under which our opinion was sought. I request permission to see the patient, a copy of the patient’s operation notes and other relevant data. In almost all cases, these have been readily provided.