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I am LOLing...

randomdoc1

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    Ok, so I got a call from one of my major referral sources saying she needed to make an appointment with me. I said okay and went ahead and scheduled her. I assumed she was talking about meeting with me to discuss future referrals, get to know me better, etc. She shows up on my schedule as a patient! Turns out the provider who was giving Adderall to everyone was seeing her as a patient and getting referrals from her. Don't worry, I'll handle this conflict of interest appropriately. I'll be referring her to some good prescribers I know. But wow, totally didn't see that one coming. Oh, and the whole Adderall thing, you guys were right. After a month of me talking to patients about Adderall and who I am and am not comfortable with continuing the scripts with, the bogus ADHD referrals and Adderall refills requests dropped off completely. My schedule went from half of the transfers being on Adderall to 5% or something like that and no questionable newcomers either ;).

    Edit: the provider who gave Adderall to everyone was seeing this person who is a major referral source for the clinic. Now that the previous provider is not working for us, I am getting her old pts and one of them is this patient who works at a clinic herself. I thought she wanted an appointment with me to discuss referring more patients and to get to know me as a new doc in the private sector. But turned out she wanted to meet me to be a patient of mine. I get a lot of referrals from this person. So I can't be her psychiatrist. However, the previous prescriber saw her as a patient and took referrals from her.
     
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    randomdoc1

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      I'm confused. Why can't you be the psychiatrist for someone who also gives you referrals?

      It was my impression that while I was in residency that it poses a conflict of interest. Certainly first degree relatives and such are a no no. But this therapist gives me a lot of referrals and I work together with her on mutual clients we have. I'd think it could throw a little bit of a wrench in the therapeutic dynamic between psychiatrist and patient given to some degree that we work with each other.
       
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      Jules A

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        It was my impression that while I was in residency that it poses a conflict of interest. Certainly first degree relatives and such are a no no. But this therapist gives me a lot of referrals and I work together with her on mutual clients we have. I'd think it could throw a little bit of a wrench in the therapeutic dynamic between psychiatrist and patient given to some degree that we work with each other.

        I prescribe to patients' family members all the time although I'm not doing therapy. Many of my patients are referrals from other patients or colleagues. It sounds like you are considering her more of a colleague and even if that is the case I'm not certain its a definite no-no for you to treat her unless either of you is uncomfortable. It will be interesting to see what others think.
         

        calvnandhobbs68

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          I prescribe to patients' family members all the time although I'm not doing therapy. Many of my patients are referrals from other patients or colleagues. It sounds like you are considering her more of a colleague and even if that is the case I'm not certain its a definite no-no for you to treat her unless either of you is uncomfortable. It will be interesting to see what others think.

          Wait what? You don't see the conflict of interest in being the doctor for a person who refers patients to you? I can spell out a few scenarios for you pretty easily 1) The person may be afraid to terminate your relationship if he/she thinks that you may not see their patients anymore afterwards. 2) You might be inclined to give that person preferential treatment/give in to demands more easily if you're afraid you might lose some referral base 3) The person may be inclined to refer more patients to you to "keep you happy" if they like you as their doctor. Probably a lot more complex scenarios that might play out. Although I'm sure this is legally allowable (e.g. wouldn't fall under any anti-kickback laws) I'd doubt it would be ethically allowable.
           
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          Jules A

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            Wait what? You don't see the conflict of interest in being the doctor for a person who refers patients to you? I can spell out a few scenarios for you pretty easily 1) The person may be afraid to terminate your relationship if he/she thinks that you may not see their patients anymore afterwards. 2) You might be inclined to give that person preferential treatment/give in to demands more easily if you're afraid you might lose some referral base 3) The person may be inclined to refer more patients to you to "keep you happy" if they like you as their doctor. Probably a lot more complex scenarios that might play out. Although I'm sure this is legally allowable (e.g. wouldn't fall under any anti-kickback laws) I'd doubt it would be ethically allowable.

            Interesting points, thanks for replying. Hopefully others will chime in also. The OPs situation is somewhat different although I remain curious as to how the 1st degree relative rule came about. To clarify my very part-time OP docket is jammed so I don't have or need anyone feeding me multiple referrals on a regular basis. In fact I'm doubtful anyone is that enamoured with me or my prescribing to feel trapped and I guarantee there isn't anything I ever prescribe that could be considered suspect of preferential treatment.
             

            cbrons

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              Ok, so I got a call from one of my major referral sources saying she needed to make an appointment with me. I said okay and went ahead and scheduled her. I assumed she was talking about meeting with me to discuss future referrals, get to know me better, etc. She shows up on my schedule as a patient! Turns out the provider who was giving Adderall to everyone was seeing her as a patient and getting referrals from her. Don't worry, I'll handle this conflict of interest appropriately. I'll be referring her to some good prescribers I know. But wow, totally didn't see that one coming. Oh, and the whole Adderall thing, you guys were right. After a month of me talking to patients about Adderall and who I am and am not comfortable with continuing the scripts with, the bogus ADHD referrals and Adderall refills requests dropped off completely. My schedule went from half of the transfers being on Adderall to 5% or something like that and no questionable newcomers either ;).

              Edit: the provider who gave Adderall to everyone was seeing this person who is a major referral source for the clinic. Now that the previous provider is not working for us, I am getting her old pts and one of them is this patient who works at a clinic herself. I thought she wanted an appointment with me to discuss referring more patients and to get to know me as a new doc in the private sector. But turned out she wanted to meet me to be a patient of mine. I get a lot of referrals from this person. So I can't be her psychiatrist. However, the previous prescriber saw her as a patient and took referrals from her.
              Very confusing story.

              Why dont you use the term "NP" as opposed to "provider" or "prescriber."
               
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              TexasPhysician

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                Wait what? You don't see the conflict of interest in being the doctor for a person who refers patients to you? I can spell out a few scenarios for you pretty easily 1) The person may be afraid to terminate your relationship if he/she thinks that you may not see their patients anymore afterwards. 2) You might be inclined to give that person preferential treatment/give in to demands more easily if you're afraid you might lose some referral base 3) The person may be inclined to refer more patients to you to "keep you happy" if they like you as their doctor. Probably a lot more complex scenarios that might play out. Although I'm sure this is legally allowable (e.g. wouldn't fall under any anti-kickback laws) I'd doubt it would be ethically allowable.

                Disagree

                I'd have to put up a sign saying that I don't treat medical professionals or their families if this were true.

                There are many local counselors and physicians that refer patients to my clinic. Many also have children. There is a shortage of child psychiatrists, and I run a cash-only practice (everyone gets special treatment compared to a regular clinic). Having these children wait months on a waitlist elsewhere for treatment because their parent may one day send an extra patient my way or cut-off referrals seems crazy. I would think that most medical professionals don't calculate monthly referral numbers per provider to even know if a change occurred. I'd never know, and my practice is smaller than most.

                If anything, I'd argue that all providers should be giving special treatment to other medical professionals. We should take care of our own. This has been the case for centuries. My dermatologist won't accept my money or any other physicians' money. I get discounts at my optometrist. Physicians have given me their personal number if my condition doesn't improve. All site professional courtesy which is a long-standing tradition in medicine.

                While I would refer close relationships elsewhere if they wanted in-depth therapy, I see no legitimate conflict in ADHD management or similar treatment. I sure hope the local emergency room docs/cardiologists, etc. feel the same way if I ever end up there.
                 
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                randomdoc1

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                  Interesting input from everyone, really nice to see the different perspectives others have. Perhaps I came from a more strict school of teaching. In my medical school and residency, they've emphasized things like not to treat your own first degree relatives and some even suggested friends of relatives. Where do we draw the line and where does it no longer pose a conflict of interest? That is a great question I admit I really don't have a great answer to. Since in my visits I do perform psychotherapy on most of my patients and this person I have in mind is a therapist herself, that may be a unique situation still quite open to debate. I do have to agree with calvnandhobbs in this particular situation though. The clinic she is at has been a great referral source and for over several years. If this person where to have a crisis or other things were to arise (e.g. surprise severe personality disorder, potential boundary crossing, me feeling like I owe preferential treatment, etc.) it would make me concerned about the relationship my practice has with hers. I also don't want referrals (that otherwise would have never been made) getting sent over just because they feel like they have to. It is probably much cleaner to have her see someone else. I know local psychiatrists who I graduated with that would gladly continue her care and I'd feel confident in their abilities. I do agree it can become a very thin line though given the number of different scenarios that can arise.

                  The points brought on by others are ones I never thought of and are quite good. It really got me thinking. For example, if there is a shortage of doctors, how ethical is it really to have someone wait say 6+ months for a specialist? Also, we've all come across providers where we questioned their clinical judgment. Especially if there is a shortage, is it really better to have that person potentially end up under the care of someone you question?
                   
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                  Shikima

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                    Aside from the major influx and requests for Adderall, treating of your own is sometimes necessary. This discussion shows how the treatment of mental illness is still stigmatizing and prevalent within our own professional circles.
                    You may work in an environment where the insurance you accept is HMO and if your clinic is the only clinic that is tier 1 (in network), you may see your peers and needs to negotiate that obstacle.
                     

                    calvnandhobbs68

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                      Disagree

                      I'd have to put up a sign saying that I don't treat medical professionals or their families if this were true.

                      There are many local counselors and physicians that refer patients to my clinic. Many also have children. There is a shortage of child psychiatrists, and I run a cash-only practice (everyone gets special treatment compared to a regular clinic). Having these children wait months on a waitlist elsewhere for treatment because their parent may one day send an extra patient my way or cut-off referrals seems crazy. I would think that most medical professionals don't calculate monthly referral numbers per provider to even know if a change occurred. I'd never know, and my practice is smaller than most.

                      If anything, I'd argue that all providers should be giving special treatment to other medical professionals. We should take care of our own. This has been the case for centuries. My dermatologist won't accept my money or any other physicians' money. I get discounts at my optometrist. Physicians have given me their personal number if my condition doesn't improve. All site professional courtesy which is a long-standing tradition in medicine.

                      While I would refer close relationships elsewhere if they wanted in-depth therapy, I see no legitimate conflict in ADHD management or similar treatment. I sure hope the local emergency room docs/cardiologists, etc. feel the same way if I ever end up there.

                      I think the major difference here is that this "patient-provider" is a major referral stream for the OP. If it was just another random medical professional, then whatever. It has nothing to do with "stigmatizing" mental illness. It would be no different if he was the primary care provider for that person.
                       
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                      Jules A

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                        Our state medical board just disciplined some doctors recently because those docs prescribed controlled substances to friends and family.

                        I don't ever prescribe for my family, thankfully I have plenty of friends who can do that prn lol, and of course controlled substances are certainly subject to scrutiny but I have to wonder in the above cases of friends if they were disciplined for not keeping appropriate documentation because that is where it can can be problematic.
                         

                        TexasPhysician

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                          I think the major difference here is that this "patient-provider" is a major referral stream for the OP. If it was just another random medical professional, then whatever. It has nothing to do with "stigmatizing" mental illness. It would be no different if he was the primary care provider for that person.

                          Say the counselor wasn't a current referral base. I could provide special care in order to gain a referral source. I could provide such good care that the counselor becomes a major referral source. The counselor could not like me and start convincing my patients seen at their clinic to a 2nd opinion elsewhere.

                          In any scenario in which I treat a local counselor, there exists a theoretical ethical issue described in above posts.

                          Should I refuse to treat counselors, Fire them when they refer patients, or .....?

                          There is no way to completely avoid all issues when treating any medical professional. As it's unavoidable, I see no reason to treat the situation differently.
                           

                          Mad Jack

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                            Disagree

                            I'd have to put up a sign saying that I don't treat medical professionals or their families if this were true.

                            There are many local counselors and physicians that refer patients to my clinic. Many also have children. There is a shortage of child psychiatrists, and I run a cash-only practice (everyone gets special treatment compared to a regular clinic). Having these children wait months on a waitlist elsewhere for treatment because their parent may one day send an extra patient my way or cut-off referrals seems crazy. I would think that most medical professionals don't calculate monthly referral numbers per provider to even know if a change occurred. I'd never know, and my practice is smaller than most.

                            If anything, I'd argue that all providers should be giving special treatment to other medical professionals. We should take care of our own. This has been the case for centuries. My dermatologist won't accept my money or any other physicians' money. I get discounts at my optometrist. Physicians have given me their personal number if my condition doesn't improve. All site professional courtesy which is a long-standing tradition in medicine.

                            While I would refer close relationships elsewhere if they wanted in-depth therapy, I see no legitimate conflict in ADHD management or similar treatment. I sure hope the local emergency room docs/cardiologists, etc. feel the same way if I ever end up there.
                            There's a difference between seeing one of your major referral sources and seeing any old person that sends you referrals on occasion. If they're a major referral source, you might feel compelled should they ask you for certain controlled medications, they might feel obligated to refer patients to you, etc.
                             

                            hamstergang

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                              In any scenario in which I treat a local counselor, there exists a theoretical ethical issue described in above posts.

                              Should I refuse to treat counselors, Fire them when they refer patients, or .....?

                              There is no way to completely avoid all issues when treating any medical professional. As it's unavoidable, I see no reason to treat the situation differently.
                              Any person is a potential family member in the future, so should you just not treat any person, or just treat all people since it's unavoidable? Both options are absurd, so I don't much like this line of reasoning.

                              I think people you have a professional relationship with are in a gray zone that warrants consideration. Some you may treat and some you may refer out, but in either case you give it some thought.
                               

                              michaelrack

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                                I agree that some areas are gray zones, and how you handle it depends on the circumstances. IF you are the only psychiatrist within 50 miles, seeing the person would be reasonable. If you are in New York city and the person has insurance/$ that is widely accepted by psychiatrists, referring out a major referral source would be the ethical thing to do.

                                On the other hand, medical ethics went out the windows in the 90's so now all that matters is if you follow the strict letter of the law (Stark, anti-kickback, etc). So do whatever allows you to sleep at night
                                 
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                                TexasPhysician

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                                  Any person is a potential family member in the future, so should you just not treat any person, or just treat all people since it's unavoidable? Both options are absurd, so I don't much like this line of reasoning.

                                  That's exactly my point. It's impossible to have a defined cut-off point for every practitioner, except direct family. It's not an ethical problem as much as setting your own limits.
                                   
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