Consider Your Motives Before Taking on Someone Else’s Patient

A patient makes an appointment for a medication consultation, notes unhappiness with his or her therapist, and asks if you will provide both medication management and psychotherapy. Alternatively, you refer the patient to a colleague for a second opinion, and the next thing you know, the patient has transferred care to this colleague.

As common as this experience may be, it can be hard to tell if the patient’s decision to transfer care is based on a legitimate need, if it stems from the patient’s acting out a transference dynamic, or if it is the result of aggressive patient recruitment by another clinician.

While there is not a specific written prohibition against “stealing” patients from colleagues, there are sections of APA’s Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry that may apply.

Boundaries of Doctor-Patient Relationship

Section 1, Article 1, of APA’s Principles states, “A psychiatrist shall not gratify his or her own needs by exploiting the patient. The psychiatrist shall be ever vigilant about the impact that his or her conduct has upon the boundaries of the doctor-patient relationship and thus upon the well-being of the patient. These requirements become particularly important because of the essentially private, highly personal, and sometimes intensely emotional nature of the relationship established with the psychiatrist.”

When a patient approaches you about transferring care, you must consider whether you are agreeing with a patient’s request to transfer care to you because you like this patient and want to fill another hour in your schedule or if you believe that you have a skill that the other clinician lacks and is required for this patient’s treatment. While the latter may be true at times, it is important to guard against arrogance or self-deception.

If you believe that you can offer a more effective form of treatment, you must communicate the nature of the treatment to the patient. Section 8, Article 4, of APA’s Principles asserts, “In informing a patient of treatment options, the psychiatrist should assist the patient in identifying relevant options that promote an informed treatment decision, including those that are not available from the psychiatrist or from the organization with which the psychiatrist is affiliated.”

While it is appropriate to present transfer of care as a treatment option, it should not be presented as an imperative. There should be a full informed consent discussion about the patient’s treatment options, including an exploration of the patient’s motives for changing providers.

A variety of potential consequences of transfer should be considered, including clinical improvement in the patient’s condition, clinical deterioration, and a missed opportunity to work through a transference enactment. While less important than the effect on the patient, you may also want to consider the effect such action will have on you. “Stealing” a patient can lead to deterioration in trust between colleagues and damage your reputation.

Talk With the Other Clinician

When approached by a patient who wants to transfer his or her care, it is preferable to pause before agreeing, taking time to consider your own motives. Talking with the other clinician may be the right next step. Is the patient repeating an old dynamic pattern, such as rejection of caregivers based on a childhood experience of disappointing caregivers, which could be handled better through therapeutic exploration? How might the patient have distorted what he or she reported to you about the other therapist? This concern about the patient’s motivations must be balanced by the need to respect a patient’s autonomy to choose his or her provider.

It is awkward to call colleagues to discuss taking over the care of a patient or to ask them why they have taken over the care of your patient. Ideally, we are sufficiently respectful of each other’s professionalism and can engage in an honest, collegial, and productive discussion.

When we have the courage to make these calls and to respond to them with professionalism, we uphold our fiduciary responsibility to the patient, to place the patient’s best interests above our own. We also advance the collegiality of the profession and reinforce for ourselves the wisdom of seeking the ethical path. ■