Referral patterns of physicians have a direct impact upon the care of patients, particularly in obstetrics and gynecology. The choice of referral is influenced by the history of specialization, physician altruism, and intricate patterns of financial conflicts of interest. The conflicts of interest are further obscured by the lack of clear definition of roles and responsibilities for generalist, specialist, and subspecialist. Alternate patterns for referral based on financial incentives or directed referral care plans are reviewed to examine the potential conflicts of interest. An ethics-based format for referral is outlined to address these conflicts of interest.