HARVARD MEDICAL SCHOOL PRIMARY CARE REVIEW

The Art of the Referral

February 13th, 2019

 



In our current practice of medicine, many people don’t understand what a primary care physician (PCP) does. Some are disillusioned that the PCP serves as a glorified receptionist, just sitting in their offices to pass out referrals to specialists, the real doctors.

Often, patients call my office for a referral to a specialist based on a problem that we never treated them for. Many people don’t understand why the receptionist cannot just give them a referral. A referral involves medical decision making and is part of the treatment process; it needs medical training and thinking to make an appropriate referral.

 

What is needed to make an appropriate specialist referral?

Need to know the right time: PCPs are not just referring out what we don’t know; we need to be excellent diagnosticians.  I rarely refer out a patient unless I have a diagnosis. This saves the specialist time and a treatment plan can be implemented more rapidly. On the other hand, if we wait too late to refer a patient, we may be putting them at risk of an adverse outcome. Timing is key here. Too soon dumps much of the work unto the specialist and it may turn out that, in fact, the wrong specialty was chosen.

Need to have the right reason to refer the patient: Despite the fact that most PCPs refer judiciously, I have witnessed many that are easy to refer patients out. They may be heading on vacation and are just dumping off the work on someone while they are gone. This has in fact happened to me on occasion when a specialist referred a patient to me because they were heading out on a voyage. Or, they may have a difficult patient that they just don’t want to deal with. But, these are not good reasons to refer patients. As a PCP, we are responsible for the whole well-being of that patient. If we refer a patient to a neurologist, for instance, that doesn’t mean that we no longer have any responsibility over that patient’s brain or nervous system. A referral should be made whenever anything is outside our sphere of expertise. If we have a patient that we can’t figure out, there is nothing wrong in referring out for help. None of us know everything and it is the patient’s best interest when we know our limitations and act on them. And it may simply be because the patient requests a referral. I usually comply unless I feel the referral doesn’t make sense.

Need to know the right specialty:  We need to refer to the right specialty. If we do not, we just slow down the diagnoses process. While many diseases may not be life-threatening, it is very anxiety-provoking for patients not to know their diagnosis or how it will be treated. We should act in a fashion as to make this time the least possible.

Need to know the right specialist: Even within a specialty, some doctors sub-specialize. I see this often with orthopedists: some treat only shoulder problems, some only back pain. If a patient has a broken wrist, it does not make any sense to refer to someone who only treats back problems. We need to learn who treats what and refer appropriately.

Need to remember that babies and kids can’t give accurate histories: Most kids can’t give us an accurate history. Many times we are trying to make best estimates and inferring diagnoses from symptoms a parent is giving. When dealing with pediatric patients, we always need our radar on that there may be something else going on that no one is telling us.  Because kids are still growing and developing, a missed diagnosis may have disastrous results. Sometimes, referrals are more urgent in this age group.

Making a referral, thus, is not merely handing off care to a specialist or providing a patient with the correct paperwork to ensure coverage is made by the patient’s insurance company. Rather, it is a medical decision that incorporates clinical judgments. To be effective and to get patients diagnosed and treated quickly, appropriate referrals need to be made because when bad referrals happen, delays ensue and data falls through the cracks.

 

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