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Consultation-Referral Among Physicians: Practice and Process Consultation-Referral Among Physicians: Practice and Process T. C. Saunders, MD Calgary, Alberta Consultation-referral is a part of everyday family practice. Al­ though the process is taken for granted, it is a complex phenomenon. Neither the practice nor the process always meet the expectations of the referring physician or the consul­ tant, and the patient may be the worse because of this discrep- any. Studies of the practice and the process support this view. A model of the process is elaborated which can be used for the teaching of medical students or residents and which the prac­ ticing physician may use to improve his/her consultation- referral practices. The words “consultation” and “referral” re­ communication—the practice and process of con­ flect the complexity of medical practice and imply sultation and referral between physicians—and that a physician cannot be all things to his/her pa­ will propose a model for the teaching of both. tients and community. Fifty years ago a physician The term “referral” is usually used to denote may have been able to fulfill such a role, depend­ the practice whereby one physician gives over the ing upon the physician’s degree of isolation, skill, care of a patient to another physician who has and knowledge. Nowadays, communication particular expertise, knowledge, or use of a facil­ technology and the availability of air travel make ity. The term “consultation” usually denotes the possible startling examples of compression of time practice whereby one physician consults with and distance. For example, a man suffering chest another about a patient with the implication that pain while working on a drilling crew in the Cana­ the first physician will continue to care for the dian Arctic, having the benefit of a paramedic who patient during and after the consultation. In some is able to communicate with a physician, is in an parts of the world the term “consultation” is also intensive care unit in a hospital close to his family used to denote any physician/patient encounter, within a few hours of his attack. These but this is not the sense in which the word will be conditions—the increasing complexity of medical used here. In this paper, these terms will be used practice, the ease of transportation, and the interchangeably in the belief that they represent technology of communication—also serve to high­ the extremes of a spectrum of activity, the under­ light the problems of communication between lying process being very similar throughout the health-care professionals. This paper will re­ spectrum. view the literature of one aspect of this Present Practice From the Department of Family Medicine, Foothills Hospi­ Family physicians consult with all other physi­ tal and the Division of Family Practice, University of Cal­ gary, Calgary, Alberta. Requests for reprints should be ad­ cians and the rate of referral is fairly constant in dressed to Dr. T. C. Saunders, Division of Family Practice, different areas of the world. Geyman, Brown, and University of Calgary, 1611 29th Street NW, Calgary, Al­ berta T2N 4J8. Rivers1 compared referral patterns of family THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 1, 1978 123 CONSULTATION-REFERRAL AMONG PHYSICIANS physicians in the eastern and western United percent over the past seven years.* Thus, if about States, rank ordering the referrals according to one half of a family physician’s hospital admis­ specialty. General surgery, orthopedics, and sions have a consultation, then Greenhill’s two obstetrics /gynecology were the first three in each physicians probably refer the same number of pa­ area, followed by a number of subspecialties. In­ tients. ternal medicine and pediatrics were well down the Clute6 estimated that 30 percent of the physi­ list. Geyman et al suggest that differences in the cians in his study saw and treated patients who rank order and the absolute number of referrals to should have been referred to specialists. This opin­ some subspecialties may be a function of the ion seems to be at variance with Geyman’s study, availability of those specialists. The average re­ which suggests that family physicians provide ferral rate in each area was around two percent. definitive care in 98 percent of the patient visits in Morrel2 studied the practices of three general daily practice. Geyman correctly points out that practitioners in suburban London, England the quality of care issue has not been addressed in (United Kingdom general practitioners do not his as in most studies about consultation-referral. usually have hospital appointments in urban cen­ The College of Family Physicians of Canada,7 ters) and found rates of 15 percent for the older (which commissioned Clute’s study) describes physician, and 22 percent for the two younger how a certified family physician ought to behave iq physicians. This suggests that age and experience “ using the ancillary and consultant service to in­ may be factors in referring fewer patients, but the sure exemplary healt|i care.” The objectives younger physicians used more laboratory and which cover this area state that “(a) the physician x-ray assistance and examined more systems, both shall suggest and arrange an appropriate consulta­ factors that had been previously correlated with tion if he has not established a satisfactory defini­ higher referral rates. There was also evidence that tion of the problem in his or the patient’s mind, (b) the physicians had higher rates in their particular the physician shall obtain suitable consultation interest areas, or in specialties in which they had indicating to the consultant his reasons for the extra postgraduate training. consultation and his expectations, (c) the physi­ Co I Iyer1 studied the treatment of emotional and cian shall demonstrate his knowledge of a health psychosomatic illnesses provided |iy eight family professional’s ability in tailoring the choice of physicians in southern Ontario. Hp found that 93 health professionals to suit the needs of a specific percent of the patients with these illnesses were patient and family, (d) the physician shall tactfully treated by the family physician, 12 percent were and ethically obtain another consultation when sent for consultation, and eight percent required dissatisfied with one consultant’s opinion, insuring consultant care for all of their treatment. Riley4 that both are aware of the circumstances, (e) the obtained 103 completed interviews from 146 gen­ physician shall continue to follow closely patients eral practitioners in the 11 counties surrounding whose supervision he has referred to other health Rochester, New York. The sample included 34 professionals.”7 percent of the urban practitioners and 23 percent This emphasis on the importance of consulta­ of the rural practitioners. The rural practitioner tion in the provision of high quality health care referred patients at a rate of three percent versus receives support from society as well as the pro­ five percent for his urban counterpart. Riley found fession. Williams8 interviewed a random sample of no difference between the referral rates of the physicians in North Carolina to determine the rea­ older and the younger physicians in either setting. sons for referral to a university center. He found Greenhill5 studied two urban general practitioners in Elberta and found that the physician without hospital affiliation referred 6.3 percent, while the other general practitioner referred 3.4 percent and admitted 5.9 percent of his patients to hospitals. At another general hospital in Alberta with a de­ partment of family medicine, the average consul­ *Physician Activity Study data, Foothills Provincial General tation rate of the 50 patients admitted to that hos­ Hosptal, Calgary, Alberta. 1970-1976. Available from au­ pital by family physicians has remained around 45 thor. 124 THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 1, 1978 CONSULTATION-REFERRAL AMONG PHYSICIANS that 48 percent of the referrals were initiated medicine,” and “ability to study patients,” was primarily by the patient. Of the remainder, 30 per­ the quality “readily refers patients when it is to cent initiated by the physician were for their advantage to do so.” Ranking tenth from the nonspecific reasons and only 22 percent were for most undesirable quality, which read, “is negli­ specific reasons. gent in handling of patients,” was the quality Larsen9 surveyed a random sample of 1,000 res­ “ holds on to patients to undue degree: disinclined idents in Calgary on Patient’s Expectation of the to suggest or seek consultation; apt to be offended Family Physician. Nine hundred seven question­ if patients request consultations or a transfer to naires were completed by the head of the house­ another doctor.” hold, either male or female. Less than 25 percent The decision to refer is the key to the practice, (range 12 to 25 percent) said they thought it of little but how well the process of consultation or re­ or no importance that their family physician used ferral is carried out is also important. Cummins the community health care resources which were and Smith11 received follow-up information in 75 available. percent of 200 referrals, after a waiting period of How society in general thinks about the impor­ 60 days. Sixty-five percent of university-based tance of consultation-referral practice in health subspecialists provided the information, whereas care is best illustrated by a study by Price.10 He 90 percent of private subspecialists provided developed a set of criteria for physician per­ follow-up. In making the referrals, the referring formance in the patient care area. To arrive at this physicians provided a letter and contacted the set of criteria, he asked a large number of practic­ consultant by telephone in each case. ing physicians what they considered to be the Kunkle,12 a consulting neurologist at a univer­ basic factors of success in their specialty and what sity hospital in the southeastern United States, characteristics they felt to be most important in kept data on 100 consecutive referrals of private providing outstanding patient care.
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