Referral Etiquette

Family doctors refer to specialists in ever increasing numbers, but aside from observing how this is done by their preceptors during residency  training, there aren’t a lot of hard and fast rules about referrals.  A referral means a request from one physician to another for the consultant to see, assess, and possibly offer treatment and ongoing follow up to a patient. Now I am a surgeon who receives dozens of referrals every week.  I also do referrals for patients myself when it becomes clear another specialist or surgeon could offer better management of the patient than I can, or for follow up treatment after cancer surgery. It is clear that while most family doctors know how to refer appropriately,  some do not, and so, here are my basic rules about referrals.  I am only going to cover elective referrals here, not those that come from inpatients or the emergency room.  The referral system in Ontario is random, with no structure or guidelines which, in my view, are badly needed.  An online specialist compendium is coming to Ontario, which will help educate family doctors in which specialists see what problems.   But as fewer family doctors and specialists work in hospitals and do not have face-to-face relationships with each other, the system is becoming more dysfunctional.  So here is my general advice (with a surgical perspective, as usual).

  1. Who should the referral go to? If you have a specialist who is covering on call for your geographical area, generally not only emergency, but all elective referrals should be going to that person. That’s the deal. The person is putting their life on hold to offer on call services and therefore should also receive all the easier elective referrals for their operating room lists (and to justify the expense of running their offices). Having a patient somebody else has operated on show up in emergency room (because patients will always be told, and will always go to the closest geographical emergency room) with a complication you as the on call person then have to deal with is completely unfair. You should not be referring your patient a two hour drive away to see your med school buddy from 30 years ago. Not cool. As people join practices, retire, and practice patterns change, referral patterns need to change as well. If there is more than one person covering a service, divide the elective referrals up evenly.  Just FYI surgeons love referrals that actually involve surgery. We do the other ones (sometimes referred to as garbage referrals), but don’t send us the garbage without the good stuff coming our way as well.

2. Who sees what? This becomes very difficult as specialists sub-sub-specialize within their fields to very narrow areas of practice- neurologists who only see multiple sclerosis patients for example. If you are not sure what someone sees, ask! Even sending the referral will sometimes get you the name of an appropriate person to contact. Some specialists refuse to see referrals from out of their geographic areas, but that is not part of my practice. I do not mind an email, text, or call from family doctors about whether or not referrals are appropriate or for urgent stuff. Don’t assume what people do and do not see in their practices- again ask. While large teaching hospitals with huge marketing budgets would like us to think community generalists do not give as good care as they do, this is simply not true most of the time. Most problems are straightforward, and most physicians are pretty good at recognizing complex problems or patients that need to be referred on to a larger centre.

3.  Multiple referrals to the same type of specialist. Specialists generally screen their referrals pretty carefully (I go through mine individually) and see urgent stuff, well, urgently. If you think it is urgent, put that on the referral. I HATE it when GPs refer the same patient to multiple surgeons to see who will “get the patient in first.” While I realize this may come from good intentions it is just a complete waste of everyone’s time and a lot of money. It is totally unprofessional, inappropriate and should not be allowed within our socialized health care system. Most of these multiple referrals are done for non-urgent problems in vocal patients. This then uses up a spot in which a patient with an urgent problem could have been seen as most of these patients will no show for one of the two appointments. If they do show up to both appointments they are either getting redundant care, or end up confused if they get different advice from two specialists. Second opinions should be just that, second, AFTER a first opinion has been given.

4.  Patients should know why they are being referred. Some of my patients have no idea why they are coming to see me in the first place which can result in a lot of confusion and anger. And this happens not just in older or cognitively impaired patients.

5.  Send the information.   A lot of patients tell me they are having gallbladder problems with a normal gallbladder on their US. I can’t take a patient to the operating room based on their knowledge of what they think their investigations showed. I need the reports that are relevant to the problem I am seeing them for in order to make a decision. I also need their demographics, health care number, and contact details.   I do not need cholesterol levels for someone having biliary colic though.

6.  Do not refer me someone else’s problems. Particularly surgical. Several times a year, I am asked to see reasonably early complications from another surgeon, and the patient has not even followed up with the original operating surgeon. Surgeons should be looking after their own complications, in general, particularly for elective outpatients in the short term, or should at least have a go at it before someone else has to step in if the relationship breaks down. I am really unhappy to get these referrals and will generally send it back to the GP with a request to contact the original surgeon. If you want me to see them, send them to me in the first place. If you are referring to someone who is not following up their own surgical complications, maybe you need to rethink your referral pattern.

7.  When a perfectly healthy person has seen 17 specialists in the last 18 months and nothing substantive has been found after exhaustive investigations, you (and your patient) need to rethink things. You, the GP, is the one with the knowledge of the patient from a broad perspective and an ongoing relationship. A lot of mental health problems masquerade as physical complaints due to our society’s disdain of psychiatric issues, and it is pretty obvious when this is happening. Sometimes the tough conversation is needed. I see this in my office on a regular basis and I know my GP colleagues do as well.

8.  What should you and your patient expect from your referral? An appointment in an appropriate period of time, or a note saying why you will not see the referral and ideally a suggestion as to whom to refer the patient to. GPs should also expect notes on the encounter and its outcome for each visit to a specialist; this is just standard of care. The notes also give the specialist opportunity to educate the GPs on treatments or guidelines. The note should outline the specialist’s thoughts on ongoing treatment, investigations, or procedures necessary, and what they expect the GP to do. This avoids confusion and the ball being dropped. Along with this, I would like it if GPs actually read my letter. It is fine with me (although not necessarily all people would agree) if the patients read the letter/note. I think the day is fast coming where patients will have full access to their medical records.

A new eConsult service has started which allowed online referrals (usually questions as to whether a referral is appropriate) to various specialities in Ontario. This is a terrific service, avoids a lot of unnecessary visits and I would encourage all GPs to sign up for it. Until then, happy referring.

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4 thoughts on “Referral Etiquette

  1. “GPs should also expect notes on the encounter and its outcome for each visit to a specialist; this is just standard of care.”

    Not True.

    At present fee levels and considering the costs of making and sending notes for follow-up visits, these would essentially be unpaid services for some specialties in some provinces.

    Be careful when you define standard of care without adequate knowledge. Current fee guide rules in this province require such notes for consultations only, and not for follow-up visits unless circumstances require it (change of medication or diagnosis, for instance).

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    1. So you think it would be ok for a specialist to see a patient in follow up, adjust some of their medications, and not send a note back to the patients GP over what transpired between you and the patient? I disagree with this and I would recommend checking with CMPA and your provincial college that this is an acceptable practice. Even if it is not “standard of care”, I use these letters to document my encounter with the patient and it is not a lot or work or effort to then send them to the GPs. I would recommend doing them to the GPs for each patient encounter. What would be useful would be for the entire circle of care to see all letters written, more communication not less.

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    1. There is no billing code for sending a referral in Ontario. Meaning the GPs do not get paid to send referrals by the OHIP payment plan. There should also be no payment exchanged for GPs to send referrals or any payments to GPs for procedures done on their patients by other parties. An exception is eConsult where the sending (referring) GP does receive a fee (from the government) to send the referral to a consultant online- usually in this case the eConsult is asking if the referral is even necessary.

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