Facharzt für Innere Medizin, Steinach, Switzerland
Freedom of choice sounds somewhat like a political slogan [1, 2]: “Fewer regulations, more responsibility”, as our liberal party proclaims in its election propaganda. But as Kant says in his Categorical Imperative, “Every rational being must act as if he were always a legislating member in the universal kingdom of ends”(third formulation) .
As to whether an individual Swiss patient can choose to consult a specialist on his own initiative, what gives him the moral power to decide? The extent of the patient’s knowledge of his problem can vary enormously. If, for example, his knee hurts, he will usually rest his leg, treat the painful joint externally and possibly take an analgesic. If the pain is not relieved, he will probably consult his general practitioner (GP). After taking the history and performing some clinical exams, the physician, already knowing the patient from earlier visits, will develop a working diagnosis and recommend the best choice of treatment. In the case of knee osteoarthritis this will usually include physiotherapy and paracetamol, as well as lifestyle recommendations. If the pain increases and the treatment is inadequate, the GP will refer the patient to an orthopaedist of the GP’s choice to provide him with a new knee.
How can the patient benefit by referring himself to an orthopaedist? Ideally the orthopaedist will check whether the pain can be relieved by the same measures as those prescribed by the GP. The life expectancy of a knee prosthesis is not unlimited, so he will also want to delay a prosthetic operation. Orthopaedists are trained to judge difficult problems of the locomotor apparatus and undertake operative repairs if necessary. GPs may give care and detect abnormal courses in the case of frequent problems. Which one is the better choice when caring for knee osteoarthritis?
What happens if the gate-keeping GP is reluctant to refer the patient to a specialist? This rarely occurs in my practice. If a patient wants to see a specialist, I first discuss with him what can be expected from visiting one. If the patient insists I will refer him, even if I do not consider it to be mandatory. Especially in rigid gate-keeping systems, it takes the burden of responsibility off the GP when he knows that patients can have their own way. But what if the GP has a more rigid interpretation of the gate-keeping process and refuses to refer him to a specialist? In such cases I would recommend the patient to change his GP, a move that can be made easily by phoning his health insurance company.
Returning to Kant and our Swiss liberals, freedom is a precious good and we should be very careful to avoid losing it. But freedom works only as long as a majority does not make use of it. If everyone directly consulted their knee doctor as well as dozens of other organ specialists, prioritising the patients’ problems would become a hazardous business; moreover, the specialists would no longer be able to do the work they were trained to do, because they would be too busy substituting for the non-existent GPs instead of giving the patient his new knee.
Reply to this Letter to the Editor:http://www.smw.ch/content/smw-2012-13528/
Correspondence: Markus Gnädinger, MD
1 Rosemann T. Freedom of choice – always beneficial? SMW. doi: 10.4414/smw.2011.13328
2 Peytremann-Bridevaus I, Rufieux C, Burnand B. Freedom of choice of specialist physicians is important to Swiss residents. SMW. doi:10.4414/smw.2011.13315.
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