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August 26, 2016
THE DOCTOR-DOCTOR RELATIONSHIP
Maria Ana B. Mariano, MD.
Department of Bioethics and Legal Medicine

mother provided the later are aged and are being supported by the
TOPIC OUTLINE
colleague
I. Background of Doctor-Patient Relationship
 Out of consideration for the object of consultation and for the
II. Doctor-Doctor Relationship
physician’s duty to uphold the honor and dignity of his profession,
III. Duties of Physicians to their Colleagues and to the
no physician should meet in consultation with anyone who is not
Profession
qualified by law to practice medicine
IV. Referrals
 Every physician participating in a consultation should endeavor to
a. Reasons for Referrals observe punctuality
b. Obligations for the Specialist or Accepting  The physician should carefully refrain from making unfair and
Physician unwarranted criticisms should be made in a constructive way and
only directly and privately to physician involved
V. Case  When a physician attends a woman laboring in the absence of
VI. Professional Fees another who has been engaged to attend, such physician should
a. Fair of Appropriate Fee relinquish the patient to the one first engaged upon his arrival.
b. Considerations  The physician is entitled to compensation for the professional
c. Kinds of Medical Fees service he may have rendered
d. Unethical Fees  A true physician does not base his practice on exclusive dogma or
VII. Phone Consultations sectarian system, for medicine is liberal. It has no creed, no party
and no master
 A physician should keep abreast of the advancement of medical
science; contribute to its progress; and associates with his
BACKGROUND OF DOCTOR-PATIENT RELATIONSHIP colleagues in any of the recognized societies so that he may broaden
his horizon through the exchange of ideas
Rights Patient Physician  A physician should be upright, modest and well-versed in both the
Choose his physician Choose his patients science and art of his profession
Best Care Cooperation  It is degrading to the good name of the medical profession to
Treated with dignity Compensation prescribe, dispense or manufacture secret remedies or to promote
their use in any way; and to deliberately prolong the progress of
Privacy and autonomy protected Respect and a good
treatment
reputation
 Physician should expose without fear or favor, before the proper
Cooperate with the healthcare Provide the best care medical or legal tribunals corrupt or dishonest conduct of members
provider possible of the profession
Given all pertinent information Protect the patient’s
privacy and autonomy
REFERRALS
Follow instructions Be competent
 Referrals are done primarily to provide the patient with care that the
Give gratitude and compensation Avoid exploitation of patient’s primary physician may not be able to give fully.
to the physician patient and conduct  This is done with specific objective in mind. It may be initiated by
himself in an ethical the primary physician or the patient.
manner  The patient must be informed of this need and consent must be
obtained before referral is requested
 Attending physician should give the consultant all necessary
DOCTOR-DOCTOR RELATIONSHIP information relating to the case done away from the patient and his
 Medical Ethics is a path illuminated by principles to guide members family
of the medical profession in their dealings with each other and with  Consultant should not make any remarks about the diagnosis,
their patients etiology, prognosis or treatment or hint any possible error of the
 Doctors are caught in the pursuit of money and prestige and is attending physician
vulnerable to groupism and power struggles  A physician should not take charge of or prescribe for a patient
 As a result, doctors can knowingly or unknowingly behave in a already under the care of a mother physician, unless the case is one of
manner that detrimentally affects the position of their colleagues emergency
 They must respond to this problem by reestablishing ethical
principles, because self-regulation is better than forced external Reasons for Referral
controls through laws  Procedure: It requires the specialist to perform specific
intervention that he is trained to do
DUTIES OF PHYSICIAN TO THEIR COLLEAGUES AND TO  Evaluation: An opinion is sought regarding a specific complaint or
illness of the patient. There is no need for management suggestions
THE PROFESSION
 Evaluation and management: Aside from the expert opinion,
 Physicians should labor together in harmony, each giving freely to specific diagnostic and treatment approaches are also required. The
others whatever advantage he may have contributed. primary physician has the prerogative to have theses carried out or
 A physician should willingly render graciously service to a not
colleague, to his wife, and minor children or even to his father or

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 The Doctor-Doctor Relationship

 Co-management: The specialist is on the same footing as the  She was admitted to the Intensive Care Unit (ICU) , under Dr. C., a
primary physician. His orders for management are considered as the cardiologist who regularly saw her as an outpatient.
same level as that of the primary physician.  On the 3rd hospital day, she was transferred from ICU to a regular
hospital room. She progressively improved.
The clarity of the reason for referral also defines the  On the 5th hospital day, the attending cardiologist went out of the
extent of the relationship between the referral country and decided to leave the follow-up care of the patient to Dr.
physician and the patient. F., his fellow. Dr. C., informed the patient of this arrangement to
which the patient agreed.
 However, on the 7th hospital day, Mrs. J. developed sudden
hematemesis. Dr. F. discontinued all anticoagulants and referred the
Nature of Start of the End of the Duty to the
patient to Dr. H., a hematologist, and Dr. G., a gastroenterologist.
Referral Relationship Relationship Relay
Endoscopy was done and the patient received transfusion of blood
Information to
products.
Procedure Upon referral Upon Primary  The gastroenterologist likewise referred the patient to Dr. S., a
completion of physician surgeon, for evaluation and had Mrs. J. back to ICU. She later went on
the procedure respiratory failure and was intubated. The gastroenterologist
and initial referred the patient to Dr. P., a pulmonologist. The patient improved
follow-up but she could be not be successfully weaned off the ventilator.
Evaluation Upon referral Upon giving the Primary  On the 16th day of intubation, Dr. P. recommended that a
medical physician tracheostomy be done and referred the patient to Dr. E., an ENT
opinion consultant.
Evaluation and Upon referral Upon the Primary  The patient subsequently improved and was eventually discharged
Management resolution of physician on the 30th hospital day, while Dr. C., was still out of the country.
the condition After a month however, Mrs. J. was readmitted because of dyspnea
referred for or difficulty of breathing, this time under the care of Dr. P., the
Co- Upon referral Upon the Patient and pulmonologist consulted before.
management resolution of Primary
the condition physician Answer s to the Case Presented:
referred for
 Our case deals with the proper care of the patient.
 Communication is the Key  Leaving a patient behind definitely makes of the physician
o The referring physician must give all the pertinent patient relationship highly defective.
information to the one accepting the referral  If the physician foresees that s/he cannot personally
o For his part, the specialist side must course his attend properly to a patient, it would be better for
findings and information through the primary or her/him to refuse to accept the responsibility of being the
referring physician in order to avoid conflicts in attending physician. That would really be the more
interpretation and to allow for an orderly flow of ethical thing to do.
information from the physician to the patient  But should the trip abroad prove to be necessary but
unforeseen, in compliance with the principle of
Obligations of the Specialist or Accepting Physician beneficence, then s/he should ensure the welfare of the of
her/his patent by relinquishing his role as attending
 See the patient as soon as possible once the referral is made
physician to a worthy substitute.
 Do a full evaluation of the patient and accomplish task requested for  A worthy substitute is a consultant who can really attend
in the referral to the medical needs of Mrs. J. All of this should be done
 Leave the case once task is completed with the patient’s the informed consent.
 If no service is done, no fee should be exacted from the patient.  The new attending physician would then have a free hand
 No cross referral should be done. One who accepts the referral in managing the patient and in making proper referrals.
cannot refer to another physician.  By wanting to remain as the attending physician in
 No fee should be paid to the primary physician as a referral fee. absentia, Dr. C. has just complicated matters and might
Financial arrangements must be made known to the patient. have even jeopardized the good of Mrs. J. by assigning a
 In case of emergency and the primary physician is not available, the fellow, a Cardiologist-in-training.
specialist may take over the medical decision-making process  Proper coordination with the consultants with the
 The patient must be sent back to the primary physician at the end of consultants taken for referral was not achieved since
the evaluation and/or treatment process these consultants could not deal with the de facto
 In cases where the patient does not want to go back to the primary attending physician as a colleague
physician, what should specialist do?
 Explain the need for the patient to return to the primary physician,
emphasizing the ethics of the referral system
PROFESSIONAL FEES
 If the patient is insistent, encourage him to inform his primary
 As the medical service deals with life, the service is considered
physician of his plans. It is, however, the patient’s right to choose
priceless.
his/her physician
 Does a doctor deserve to be paid? YES!
 Inform the primary physician personally that you had seen and sent
o Firstly, according the Scriptures (Ex. 21:19) “the
back the patient. Explain the intention of the patient to follow up
physician should be paid for the cure”
with you for his specific problem that relates to your specialty.
o Secondly, the physician receives his honorarium not
for the treatment, but for his efforts
CASE/S o Thirdly, the privileges do not replace but
 Mrs. J, a 65 year old, female , was admitted for chest pains complement
accompanied by chest heaviness. At the ER, she was diagnosed as a What is a fair or appropriate professional fee?
case of Acute Myocardial Infarction (Killips III).

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 A professional fee is one that will allow the physician to practice
his profession and permit him to live without distractions
 Fees that are too low, with the intention of undercutting other
physicians and those that are too high are unacceptable
 Standard professional fees can be done by collegial agreement by
the members of the medical associations to which the physician
belong
 Referral fees for the services of patients and fee splitting is
frowned with reluctance.
 Separate fees must be issued and collected only for the services
rendered
 One can waive his fees, and is highly encouraged to a fellow doctor
colleague
 This must be done more so with immediate family members.
Considerations
 Difficulty of the case
 Expertise of the physician
 Standards in the area
 Personal relationship with the patient
 Degree of sophistication
 Paradigms for Charging Professional Fees
 Socialized Fee
o Based on the capacity of the patient to pay as his
economic status would allow
o It should behoove a doctor to turn a patient away
due to his inability to pay his professional fee, most
especially during emergency situations
o This should not be true to elective procedures
 Experience-based, Expertise-based, Specialization-based Fee
o A relative value scale must be in place to be able to
determine what a particular medical service by a
physician is worth in monetary terms
o The more experienced the doctor is, the costlier his
specialized service and product of expertise
becomes
 The Theory of Free Enterprise
o Since health is a commodity, its service has a price
o The best paradigm through which health can be
availed of is through a democratic capital-based
enterprise
o Those who wish to avail themselves of health and
its benefit must pay for it in a way that they want
 Level of Difficulty Standard Fee
o The more difficult the condition of the patient is, the
larger should be the financial implications
o This condition will necessarily need more time,
effort, gadgets and instruments and certainly deeper
intellectual diagnostic, therapeutic and prognostic
undertakings heaped up on the shoulder of the
medical personnel
o Doctors should not be treated like beggars that they
cannot be choosers, but must be treated with dignity
which they deserve to maintain in the community
Kinds of Medical Fee
 Simple contractual fee
o Physician may enter into a contractual relation with
the patient expressly stipulating the nature of
management procedure to be applied by the
physician and specifically stating the value of such
medical service, either orally or in writing
 Retainer fee
o A professional fee measured by the space of time
and NOT by the quality or quantity of medical
services rendered.
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The Doctor-Doctor Relationship
o The employer specifies the amount of remuneration
to be paid to a physician on a specified period of
time
o A physician employed by the government makes the
latter his retainer
 Contingent fee
o The value of the professional medical fee depends
upon the success or failure of the treatment
instituted
o Basically, the medical fee may be contingent upon
the result of the treatment or contingent upon the
length of time such treatment has been instituted to
give the desired result
 Dichotomous Fee
o The physician may require the services of a person
who may act as an agent to solicit patient
o Agent will then share in the medical fee, either on a
percentage basis or on a fixed amount
o 3rd person maybe an ordinary layman, physician or
any person with a variety of background
 Straight fee or Package deal agreement
o For the amount tendered by the patient to the
physician, the latter shall be responsible for the
payment of the hospital bill, laboratory fees,
medicine and other incidental expenses in the
management of patient
o The amount of medical fee is dependent on shat will
be the remaining balance when all the other
expenses have been paid
o This kind of fee is UNETHICAL because the amount
wagers with unforeseeable contingencies
Unethical Fees
 Referral fees
o A physician should not receive fees because a
referral was made to another physician or to a
health care facility
 Fee splitting
o Multiple physicians rendering services to a patient
should tender separate fees and the financial
arrangements must be made known to the patients.
 Exorbitant fee
o There may be difficulty in determining what fee is
“too much”
o The best to ascertain this would be the physician’s
peers
 Extremely small fees
o Designed to take away patients from other
physicians.
o This presents unfair competition and a lack of
professionalism
o If the fee has been lowered to help patients,
however, that is acceptable, thus the intention
therefore determines the fees propriety
Phone Consultations
 A form of telemedicine – “healing from a distance”
 Although this is done with the best intentions to help the patient,
this offset by the possibility that harm may be done in the sense that
there is no actual physical examination that takes place and the
physician relies solely on the provided information
 May be prone to abuse and may open the door to legal liabilities
 Is it an obligation to provide a contact number? NO.
 It is the physician’s right to choose patients and limit his practice
 However, if one offers this option to his patients, he must be aware
of its limitations and must inform the patient of his responsibilities
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