AMA Journal of Ethics^®

Case

Dr. Nichols, a well-established comprehensive ophthalmologist, refers Mrs. Smith to Dr. Weiman, a specialist at an academic health science center, for a second opinion on the management of her glaucoma. A warm note from Dr. Nichols to Dr. Weiman details Mrs. Smith’s 15-year history of glaucoma, refractory to multiple medical therapies and laser treatments. In his referral letter, Dr. Nichols states that, because conservative measures have failed and Mrs. Smith now has advanced glaucoma, he has offered Mrs. Smith a trabeculectomy, which Mrs. Smith has agreed to have in the coming month. Because Mrs. Smith seemed hesitant about surgery on prior visits and has expressed interest in participating in clinical trials with newer pharmacologic agents, Dr. Nichols is referring her to Dr. Weiman for consultation, specifically for her opinion on any additional conservative therapies that could be attempted before proceeding with the trabeculectomy.

Dr. Weiman greets Mrs. Smith, who professes her satisfaction with Dr. Nichols’ care—she has been his patient for over two decades—and is equally delighted to have Dr. Weiman’s opinion. Dr. Weiman examines Mrs. Smith and notes that both her optic nerves are prominently cupped and she has peripheral visual field defects that fully correspond to the appearance of her optic nerves. Her central vision is threatened by disease progression, and her intraocular pressure is elevated in both eyes despite good compliance with her medications.

Dr. Weiman tells the patient that her examination confirms Dr. Nichols’ findings, and she agrees that a trabeculectomy is indeed the best option for Mrs. Smith. She explains that there are no clinical trials Mrs. Smith would qualify for with her advanced glaucoma without risking further vision loss. Dr. Weiman concludes by wishing her luck with her surgery, but as she is exiting the room, Mrs. Smith says, “Well…I just have one more question.”

“Dr. Weiman,” she begins. “I’m glad you agree with Dr. Nichols. The fact that you’re both a professor and a glaucoma specialist means that you have great expertise with patients like me, and I don’t think I can trust my eyes to anyone but the best. I’ve been very happy with my care from Dr. Nichols, but I would prefer that you perform my surgery.”

Commentary

In this case, Dr. Nichols referred his patient to Dr. Weiman “specifically for her opinion on any additional conservative therapies that could be attempted before proceeding with the trabeculectomy.” The consulting physician, Dr. Weiman, presumably has both the extra medical knowledge and superior fellowship-based training and experience to provide such an opinion. In his referral letter, Dr. Nichols wrote that because conservative measures had failed and Mrs. Smith now had advanced glaucoma, he has proposed a trabeculectomy, which Mrs. Smith has agreed to have shortly. I believe that Dr. Nichols’s intent is perfectly clear here, and that the consultant, Dr. Weiman, should provide the opinion that was asked of her, namely that there are no “additional conservative therapies” for Mrs. Smith and that she should proceed with surgery by the referring doctor, Dr. Nichols, as planned. Dr. Weiman did exactly what a glaucoma consultant is supposed to do in this setting: she provided the patient care that was requested and rendered the opinion. In this situation the referring doctor, not the consultant, is the center of the clinical decision-making process. The consultant should not usurp the role of the referring physician.

Mrs. Smith changes the dynamic, however. In my experience, regardless of how long the encounter has been, whenever the patient says “one more thing, doctor…,” whatever follows that phrase is actually something very important to the patient and, in neuro-ophthalmology, often the critical piece of information that can make or break a case (e.g., “One more thing, doc…does it matter that my mother had the same optic nerve problem when she was 20 years old?”). She drops the bombshell: “I would prefer that you perform my surgery.” The patient, of course, is free to make this request and should indeed make her own decisions about her surgeon and surgery. To me, the question is not whether or not the patient can choose a new surgeon, it is about how a consulting doctor should communicate with the patient and the referring doctor about this potential change in their respective patient-doctor and doctor-doctor relationships.

Although there is obviously no single correct answer to this situation, let me give my impressions. I believe that the consultant ophthalmologist has an obligation to express to the patient her confidence in the surgical abilities of the referring physician (if true) and to explain to the patient that the reason for the referral was to confirm the decision to proceed with surgery and not to do the actual surgery. (The potential negative impact on the consultant’s referral base—not just Dr. Nichols, but others as well—of “patient-poaching” is a real and important consideration, but it is a business issue, not an ethical one, in my view.)

The responsibilities of the referring ophthalmologist are to provide the consultant with the clinical information, ask specific questions, and define whether the consultation is for an opinion (e.g., surgery or no surgery?) or is an actual transfer of care to the consultant (if surgery is recommended, Dr. Weiman is free to go ahead and do it). Ideally, the referring physician would tell the patient all of this before sending her to the consultant: “Mrs. Smith, I am referring you to Dr. Weiman, a glaucoma specialist, for a second opinion regarding surgery, and if she agrees that you need it then I will schedule your surgery as planned next month.”

When confronted by the awkward request that she perform the surgery instead of Dr. Nichols, I believe Dr. Weiman should take the time to explain the situation and recommend that if Mrs. Smith insists on having her surgery done by a glaucoma specialist, that she return to Dr. Nichols to make this request and cancel her surgery in person. This is common courtesy. The patient in this setting has an obligation to her referring doctor to inform him of her choice. In addition, Dr. Weiman should not take the expedient, easy, yet unprofessional road of agreeing that day to perform Mrs. Smith’s surgery.

Finally after the visit, Dr. Weiman should do the professional thing and give Dr. Nicholas a “heads-up” on the results of the encounter, reporting: “(1) Mrs. Smith does have severe glaucoma, as you correctly diagnosed; (2) as you suspected, no further conservative measures are available; (3) you should proceed with surgery, and…one last thing. Mrs. Smith mentioned wanting to have her surgery here with me, but I told her that she should return to you to discuss that as an option, and I did not agree today to perform her surgery.”

Common courtesy demands no less from a consultant in such a situation, and a phone call in this circumstance is better for the referring doctor than finding out in a letter or by other impersonal means that the consultant has just scheduled surgery on his patient. Dr. Weiman will also be able to avoid ending up with a reputation (deserved or not), as many in academia have, for stealing patients.