Self-Referral, Self-Interest…and Self-Importance

September 20, 2013
Eric Postal, MD

Discussions of self-referral rarely present new information, but they can lead to self-interest accusations and more.

On a physicians’ online forum I frequent, self-referral came up again. It’s been rehashed to the extent that one might consider the topic pureed by now. New points rarely, if ever, seem to be made. So when people start in on it again, I always assume there’s potential new legislation on the matter. Everybody then wants to make sure that the world hears about how self-referral is a Very Bad Thing…or, alternatively, that it’s No Big Deal.

The ensuing flurry of words usually contains a mixture of passion, hope, despair, stridence, bitterness, venom, and, occasionally, common sense or (*gasp*) objective logic. One might think, being somewhat scientific sorts, doctors would value and focus more heavily on the latter elements. The problem with this is that sometimes one’s opponent has a better debate-game on the subject and/or is armed with irksome tools like academic studies supporting his position.

Happily, one need not compete on equal footing. The all-purpose rebuttal: Accusations of self-interest. To appear academic, as well, suggest that the opposition’s reference sources are biased. The fun part of this is that you’re not quite calling your opponent and his colleagues liars and fraudsters, out to line their pockets by any nefarious means. Thus, if they take offense, they’re being the unreasonable ones.

Another enjoyable aspect of this approach is that it takes all the workload out of what could otherwise be an effortful debate. While the other guy is offering up multiple lines of reasoning and evidence in support of his position, you can just keep on poking him with the oblique insinuation that his arguments are based on self-interest and therefore-ta da!-devoid of merit. You have probably encountered individuals who use similar “debate” tactics in other environments:

A: I offer line of reasoning #1 in support of my position.

B: I counter with line of reasoning #2.

A: I add line #3 to my argument.

B: I insist on #2.

A: Um…well, I also have #4.

B: Fine. I still say #2.

A: [Clenching teeth a bit] I further put forward #5-12.

B: #2 beats all of those.

A: [Walks away in frustration/disgust]

B: Yaay! I win! Everyone saw that, right?

One might suggest that, as opposing camps in the self-referral wars each have items of self-interest at stake, it makes sense to consider them mutually nullified, permitting everyone to move on with more substantive aspects of the debate. This seems fair and efficient to everybody except the individuals whose “argument” contained little aside from accusations of self-interest. For instance, a clinician wanting to defend self-referral with the support of a single neurologist-penned paper would rather not match it up against a radiologist who is backed by half a dozen studies identifying self-referral’s downsides (some put forth by the Congressional Budget Office itself).

Perhaps to prevent being thusly checkmated, they’ll unabashedly claim that their self-interest is less in quantity or baseness than that of their opponents…or, with just as much claimed holiness-of-cause, deny any self-interest at all. At which point their self-importance becomes quite evident….