I refer many of my patients to specialists. I consider them my partners in practice, people who bring more to my patients than I can offer. They’re tools every veterinarian needs to learn how to wield wisely on their patients’ behalf.
But sometimes, they’re our spouses, friends and lovers, too. Which can sometimes raise eyebrows, along with some very obvious ethical concerns.
After all, there’s a reason for the “no kickback” rules that govern how we work with specialists. We’re not to be remunerated by specialists because this kind of relationship means we might be sending you to someone because we know they’ll pay us...not because they’re the very best for your pet. Same goes for nepotism and cronyism.
Sure, these rules aren’t exactly hard and fast ones. For example, it’s OK for you to hire a veterinarian to come to your practice and perform surgery or ultrasounds––because keeping your patients “in house” means you’ll earn more. And that’s unethical when you know your patients will receive better care––often for less money––when you refer them to a full-service specialty facility.
But it’s not necessarily unethical. Not if you believe that it’s what’s best for your clients and patients. And it’s certainly not illegal.
Same goes for referring patients to your spouse or love interest. It’s not illegal, but it’s ethically fraught, to be sure. And that’s why I often find myself in a pickle:
How can my clients trust that I’m sending them to the best surgeon in town for their pet’s specific needs?...when that surgeon happens to be my long-time boyfriend.
Tough one, right?
Though I confront this problem at least once a week, I typically know my clients well enough that they trust in me anyway. Whether I disclose the relationship or not, it’s a foregone conclusion (at least in my mind) that I’m doing my best for my patients by sending them to the best surgeon I know.
After all, I’d been referring to this surgeon––exclusively––for two years before I ever met him in person. His results, my clients’ universal satisfaction with his work, and his responsiveness with written reports and telephone feedback gave him a leg up on every other surgeon I’d ever worked with...then or since.
Which is why I asked him out more than five years ago after a friendly client suggested I’d be stupid not to. Sight unseen, I made the call. You can guess the rest.
But yesterday’s new client raised the issue for me more acutely. They had no reason to trust me. They had no reason to believe me when I recommended they see the surgeon of my choice (for their lame dog with no clear site of pain or injury).
So I disclosed the relationship and explained why I thought they should still consider him tops. They smiled...and told me their previous veterinarian had already recommended him. :-)
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I think as long as youdisclose the relationship each time youmake a referral, there are no ethical concerns.
Love the friendly client suggesting that you should ask him out five years ago. I see a romance novel in the making :-). How funwould that be - a romance novel in a veterinary setting?!
Ingrid King June 26th, 2009 09:07:30 AM
'Which is why I asked him out more than five years ago after a friendly client suggested I'd be stupid not to. Sight unseen, I made the call.'
I'm so sorry, but I cannot get this scene out of my head:
'You may not know me, but I think your sutures are sexy'
I'm not sure as a patient whether disclosure of the relationship would help. If you trust your vet, you trust them to make the best choice. If you don't, there could be a million reasons they make a bad referal. Knowing which scenario you should be worried about doesn't make too much difference. 'I've been using this guy for seven years and he has great results' is the best thing I could hear. Unless you're lying about the great results, I wouldn't even care if you *were* getting a kickback.
puppynerd June 26th, 2009 10:30:09 AM
I wouldn't question the relationship since it occurred AFTER you had already been referring to him.
Now, if you had never used him before, and then after canoodling decided to refer to him, I would see an ethical eyebrow being raised.
Personally, I go to my vets because I know 'em, like 'em , and above all trust 'em. I wouldn't give a hoot about the relationship- if i didn't trust 'em enough to walk in their door, I wouldn't trust their referral...
agadoresmama June 26th, 2009 12:02:06 PM
Dr. K: Honestly? As long as you disclose the relationship, I see no issue. As a matter of fact, YOU as the client/patient's doctor sits on the "hot seat" by making the referral. That would make me believe, that he truly is the best in the specialty!
After all, what would be the very first inclination should something NOT go well? So, I say go ahead and recommend the VERY best!
On the flip side, if a home-based clinic is recommending the bottom of the barrel, surely they are responsible for that too. The clinic is not opening the yellow pages and saying "here, pick one...and I'll set up the appointment", right? That referral, if not based on trust and quality, must be based on something else...hmmm, what would that be?? Favors, money split on the take? Any other guesses?
And then, I wonder, if you should take the additional step and disparage the clinic the client investigates, because of proximity, services, & equipment...wouldn't you as the client "heed" the off-the-record information?
I am curious as to what constitutes lack of ethics and conflict of interest, when a clinic does not advertise or disclose training or student labor (as in free or receipt of renumeration), and goes further by involvement via nepotism between an educational institution & advertised as "independent referral clinic"?
It has been suggested that nepotism is incidental, gees, I've been employed for 22 years, where nepotism is everywhere. It has also been suggested that possibly I am "anti-education/training", again that is so far out of line, I'm baffled. After all, the best human hospitals in the country are involved in teaching. But students in every department, interns, residents, what have you, are clearly identifiable both through name tags, different garb, and introduce themselves appropriately.
If the veterinary profession is running programs on the up & up, this is just as applicable. Off my soapbox for today...I have my Blabby Barbara's Blog for that anyways!
I am still curious, for example: What do you feel is appropriate communication between you, Dr. Wosar, and the client? (pretending it was more inconvenient, by telephone or fax)? I'd love to see some other DVMs & lic. techs jump in. Where's Hobson?
Barbara A. Albright/NH June 26th, 2009 03:30:43 PM
Under these facts, I don't see any issues currently but, of course, that could change with changes in your professional or personal relationship with him :) I do think disclosure is warranted as clients/patients tend to be upset finding such things out after the fact, many could just be uncomfortable with the surprise and have a negative knee jerk reaction.
There are Texas attorneys who make the majority of their living through referral fees and it just doesn't smell right. I regularly referred clients out to other attorneys and only took a fee in one case (a great big $1500 fee :). I just felt like I had more independence in making referrals if I didn't take a fee. I dated several of the attorneys I referred to (and several I didn't) but that was also part of the reason I knew them well enough to refer (or not).
Professional communities tend to be small in most places. There are good reasons for all the rules and laws but there's also the simple fact that these are the people a passionate professional often shares the most common interests with so...
Due to the extraordinary, record breaking heat, I'm having to take a break from my new house rehabbing but I'm going to give a website/blogging about it a try :) http://rehabaforeclosure.webs.com/
PJBoosinger June 26th, 2009 07:54:12 PM
PJB: I look forward to your updates and a very interesting topic!
Barb A./NH June 26th, 2009 09:26:29 PM
Dr. K.,
After you mentioned the connection, I personally would be comforted by that additional relationship because of my respect for you as my Vet. I know that as my Vet with full medical knowledge of my fur family member's needs that not only would I be looking over the specialist's shoulder, metaphorically speaking, but you too would be even more closely monitoring the care.
I feel confidant that without hesitation but much more eloquently, insightfully and professionally you would opine about care given to any of your patients regardless of the specialist.
...and besides you are not easily impressed!
JoAnn Livanos June 26th, 2009 11:36:14 PM
Not quite the same situation, but when I first took Louie to the teaching hospital to see the Internal Medicine specialist who ended up diagnosing his lymphangiectasia, we had already seen a dermatologist for some of his skin issues (rabies vaccine-induced ischemic dermatopathy). I'd actually not planned to see that dermatologist again for two reasons: 1) Louie's skin initially began to rapidly improve when we had started him on cyclosporine, but also 2) that dermatologist had become very cross with me for "playing around" with Louie's prescription foods (he was on i/d at the time after a bout of pancreatitis and was not doing at all well with it, so I'd begun feeding an over the counter food that he actually tolerated a little bit better).
Anyway, in going through Louie's already very thick medical history, the IM vet came across the dermatology report and asked me about the visit. I told her that I thought the dermatologist was headed in the right direction with his thoughts on Louie's issues but that he'd yelled at me about changing his food. Then I said, "Why? Do you know him?" She said, "He's my husband."
Needless to say I was a bit embarrassed, because I'd already shared with her that I was not very happy with how he had dealt with the fact that I was making decisions about Louie's food based on observation rather than what the vet had prescribed. I actually did try to feed the i/d again for a while after he'd yelled at me about this, but ended up going back to the other food, which was never totally a solution either, but was clearly better tolerated than the Hills product.
Louie's Mom June 29th, 2009 03:45:54 PM
I'm soooo lucky. I never get complaints about my partner's work. Nor do my colleagues. He's the only specialist we don't ever get complaints on (except maybe about his hospital's prices)--whether they know he's related to me or not. Yes of course, I'm proud of him for that. But that's exactly why I started using him in the first place, right?
Still, I'm always looking out for that first complaint and wondering how I'll handle it. Honestly, I don't think I would bring up that he's my SO if they ever do (and it's probably only a matter of time before someone has an issue). I'm so non-confrontational that way. And I think it would be rude to embarrass someone like that.
Dr. Patty Khuly June 30th, 2009 07:48:46 AM
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