A doctor's responsibility to refer patients to better care

A thought-provoking column in the New York Times this week raises an interesting question.

What responsibility do doctors have to refer patients to other doctors, or other hospitals, where they might get better care.

For the author of the column, Denise Grady, the answer is obvious: they must refer the patient. The science reporter and author relates the story of a relative who sought cancer surgery outside the small town where she lived after her hometown surgeon told her she'd have to wear a colostomy bag for the rest of her life.

"But she also recognized that this was a small hospital, and a surgeon who probably spent more time fixing hernias and taking out gallbladders than he did operating on cancer patients. She decided that she wanted a doctor who operated on patients like her all the time, and that the two-hour trip to a cancer center would be worth the trouble. And so it was: she found a surgeon who specialized in rectal cancer, and today she’s in good health, with no need for a bag. She might have done just as well with the local surgeon, but we both doubt it."

As Grady points out in her column, an article last fall in the journal PLoS Medicine argued that doctors have an ethical obligation to tell patients if they are more likely to receive better treatment elsewhere. The study notes that the quality of care is uneven from one hospital to the next, with volume seemingly the biggest determinant of quality of care.

The idea that doctors should refer patients to better care makes inherent sense, it seems, to many patients, but those in the field see some potential problems.

Dr. Robert J. Weil, a neurosurgeon at the Cleveland Clinic, warned that if hospitals were forced to give patients comparative information, it might lead some to avoid difficult cases, to make their numbers look better. Bioethicist David I. Shalowitz said that expecting surgeons and hospitals to disclose information about other doctors and medical centers would create an untenable conflict of interest for them and should be avoided.

The differing opinions leaves the matter pretty much unresolved, Grady says.