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. This list was patients by local physicians, taking note of the then submitted to over 100 selected individuals: presence and the extent of the information medical educators, college and medical students, supplied to him about the patient. Sixteen of the administrators, clergymen, other professional patients had illness of recent origin. Forty were people, and patients recuperating in or recently seen as office patients and the remainder were re­ discharged from the hospital. The respondents ferred for admission to the hospital. In nearly one were urged not only to evaluate the list, but to add half of the 100 consecutive referrals, the referring to and modify it. As a result, the list underwent a physician supplied either no clinical information or series of refinements until the final list consisted of sent along a brief note of introduction of little 87 positive or desirable qualities and 29 qualities of practical help. In 23 of these, the information negative or undesirable nature. A questionnaire withheld was of potential value to the consultant. was constructed with a five-point scale from “ of When such critical information was not supplied, no importance” to “of extreme importance,” and, the referring physician was reached by letter and for the negative attributes, “ extremely undesira­ useful information was received from 11 of 13 re­ ble” to “ of no importance.” The questionnaire quests made. Kunkle comments on the uncertain was submitted to 1,604 people, including a general fate of the referred patient when communication is public subsample obtained at redemption centers faulty, and on the obligation of the consultant to of a large trading stamp company in the Salt Lake report back. He then observes that “ ...atriple loss City-Ogden-Provo area. The sample included to consultant, to referring physician, and to patient health-care personnel, college students, lower results from the breakdown of referral commu­ socioeconomic multi-ethnic groups, blacks (sam­ nication....” pled across socioeconomic strata), and hippies. Long and Atkins13 found similar problems in The results were analyzed by computing means their study. The reasons given by the physicians, within groups and then using the average of the ie, heavy workload, poor-quality house staff, lack means as the rank so that no one group could dom­ of secretarial help, seem to this writer to be inate the ranking. simplistic solutions to a very complex commu­ Ranking fourth in the positive qualities behind nication problem. Support for this view comes “clinical judgment,” “up-to-date knowledge of from a number of studies of the process of

THE JOURNAL OF FAMILY PRACTICE, VOL. 6, NO. 1, 1978 125 CONSULTATION-REFERRAL AMONG PHYSICIANS consultation-referral. referring physician’s rewards may include having his patient receive proper treatment, receiving a prompt report, having the consultant refer patients to him, and increasing his prestige in the medical community. The consultant’s rewards may be the gratification of being chosen to exercise his special skills; the satisfaction of receiving a cooperative, The Process well worked-up patient; income from the consul­ McWhinney,14 writing about the process of tation; etc. The referring physician may experi­ consultation, voices the commonly held opinion ence the cost of acknowledging to the patient his that there is a referral threshold for each physician inability to diagnose or treat the illness, the possi­ which varies with age and experience. Rawnsley ble loss of the patient, the risk of improper treat­ and Loudon15 noted that differences in rates of ment by the consultant (thus reflecting on the re­ referral among six general practitioners in Wales ferring physician), or the cost of the criticism by could not be accounted for by variations in clinical the consultant for his work-up. The consultant’s severity, diagnosis, or type of patient. Interviews costs may include receiving an uncooperative pa­ with the physicians suggested that they were influ­ tient, poor communication from the referring enced by social and attitudinal factors in their de­ physician as to the purpose of the consultation, or cision to refer. Bergen’s16 findings were similar being in the position of not wishing to develop a and he makes the observation about psychiatric relationship with the referring physician. The consultations (which can be generalized to all con­ trade-off between the values that each physician sultations) that “ ...the present relationship be­ places on the rewards and costs produces a posi­ tween psychiatry and the community physician tive or negative outcome. This theory suggests a must be seen as a special case of intraprofessional number of hypotheses about the practice and tension. Although considerable attention has been process which can be tested by research. It also given to the relationship of communities to the provides a theoretical background for learning, larger society, relatively less attention has been since it views the process as rather more complex paid to special types of problematic relationships than does the idea of a referral threshold. within professional communities. The most critical of these for understanding the consultation proc­ ess is how one member of a profession is able to seek help from another about something of which he is ignorant without losing his professional de­ Teaching the Practice and Process meanor. This is regulated by largely nonrational factors....” Skills in the arranging of consultation-referral, Shortell and Anderson17 analyze the referral although emphasized in the College of Family process in terms of exchange theory which at­ Physicians of Canada objectives, are not evaluated tempts to explain human social behavior by focus­ in their certification examinations. Yet ing on the rewards and costs to individuals who consultation-referral is a part of every family choose to interact with one another. This theory practice residency program, since every family would explain the behavior of the referring physi­ physician consults with all other disciplines. Simi­ cian and consultant in this manner: the referral of a larly, acting as a consultant must be a part of every patient reflects the feelings of the referring physi­ specialty resident’s training. Perhaps, because it is cian towards the consultant, who responds in such a part of everyday experience for residents, the a way as to reward or punish the referring physi­ process is not emphasized and the practice de­ cian. The diagnostic and treatment skills of both pends on the practice of the preceptor or hospital, are required, and both must make correct re­ thus accounting for the variation and the problems sponses if the interaction is to have a positive out­ noted in the studies. come for the patient. The author believes that the consultation- Each physician may feel rewarded in several referral process ought to be taught more formally, ways, and also may experience various costs. The not left to be learned as a part of one’s experience.

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Weed18 has pointed out the dangers to the patient allows the consultant to focus on the problem for if communication between physicians is loose and which he is consulting. But more importantly, it unstructured, and emphasizes the importance of provides the consultant with a logic diary of the the problem-solving approach in recording patient referring physician’s work with the patient. It information in a structured manner. Problem solv­ would be as wrong to provide the consultant with ing lends itself to the development of a model for only a POMR as it would be unfair to ask a consul­ the teaching of the process of consultation. tant to rely on memory after asking him to see a Problem solving consists of five steps: problem patient in consultation. A formal written request sensing, problem formulation, search for so­ for consultation is a necessary part of the process. lutions, selection of one solution, and implemen- The referral letter should include: tation/evaluation. Consultation-referral can be a a. a brief statement of the problem and the rea­ part of all five steps but is more likely to be con­ son for the consultation; cerned with the search for solutions. The teaching b. information about symptoms and physical model proposed is elaborated from the problem­ findings relevant to the problem. Other problems solving approach and consists of six steps as which might have a bearing on the particular prob­ shown in the following diagram: lem should also be included; Problem —> Assessment Plan -» c. the master problem list; (consultation is indicated) d. the patient profile;

Communication with Consultant —* e. information about the patient’s and the refer­ Consultation itself -»• Follow-up ring physician’s preferences if further consultation 1. The problem itself may dictate consultation as is necessary. Information about the refer­ in multiple trauma in an Emergency Room, when ring physician’s skill, his available facilities, and several disciplines may be involved from the be­ his interest might be important in helping to decide ginning in formulating the patient’s problems. It is on follow-up treatment or investigation; more likely that the possibility of consultation and f. arrangements for the consultation should be referral is involved in the next two steps. spelled out, ie, as the responsibility of the patient, 2. Consultation in a complex situation may be in­ of the referring physician, or of the consultant, dicated to fully assess a problem or to help formu­ dehending on circumstances. late all of the patient’s problems. This is the step in 5. The consultation itself: in former times this was which a problem-solving physician begins to think often carried out in the presence of the referring of the possibility of the help of a consultant: the physician and was very formal. This rarely hap­ physician focuses on the problem and is better pens now, but a consultant friend of the author’s able to develop a dialogue with the consultant, dintates his letters to the referring physician in the rather than focusing on his own competence—the presence of the patient, a practice which must as­ threshold above which he refers patients. sist the process of communication! 3. Assessment of the problem may dictate a plan, 6. Follow-up. This can be a delicate matter since it as when a patient is referred for major surgery. involves physician-patient and physician- This step helps to focus on who should provide the physician relationships; however, if all the steps in treatment or do the investigation, when the con­ the process are followed, and if the focus is on the sultation or referral should take place, and the fact problem, then the stage is set to allow for the best that patient education is also important. The solution. problem-solving physician becomes more flexible The method of teaching will depend on local in his search for solutions. practice and curriculum. Two methods might be 4. As the studies quoted indicate, communication considered. Signall19 has used role playing in among physicians about patients is not always teaching community health consultation to school done well. Weed18 emphasizes this in his advocacy teachers, a method which might be most useful for of the problem-oriented medical record (POMR) to students of different disciplines where feelings of facilitate communication, even suggesting that the status might be involved. Focal problem teach­ patient be the custodian of his own record. This ing,20 which uses paper simulations of cases and structured record does provide the consultant with small group instruction, would lend itself to teach­ a summary of all of the patient’s problems and ing this problem-oriented model and in this

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method practice in the writing of a referral letter 8. Williams TF, White KL, Fleming WL, et al: Patient with peer evaluation is possible. Group problem referral to a university clinic: Patterns in a rural state. Am J Pub Health 50:1493, 1960 solving is an excellent format in an area in which 9. Larsen D, Rootman I, Mills JG: Patient expectations there is no single right or wrong answer. of the family physician's use of community health re­ sources. Presented at a meeting of the Canadian Associa­ tion of Teacher's of Social and Preventive Medicine. Saska­ toon, Saskatchewan, June 1972 10. Price PB, Lewis EG, Loughmiller CG, et al: Attributes of a good practicing physician. J Med Educ 46:230, 1971 11. Cummins RO, Smith RW: Letter. N Engl J Med 293:361, 1975 12. Kunkle CE: Communication breakdown in referral of References the patient. JAMA 187:663, 1964 1. Geyman JP, Brown TC, Rivers K: Referrals in fam ily 13. Long A, Atkins JB: Communications between gen­ practice: A comparative study by geographic region and eral practitioners and consultants. Br Med J 4:455, 1974 practice setting. J Fam Pract 3:163, 1976 14. McWhinney IR: The foundations of family medicine. 2. Morrell DC, Gage HG, Robinson NA: Referral to Can Fam Physician 15:13, 1969 hospital by general practitioners. J R Coll Gen Pract 21:77, 15. Rawnsley K, Loudon JB: Factors influencing the re­ 1971 ferral of patients to psychiatrists by general practitioners. 3. Collyer JA: An evaluation of treatment in family Br J Prev Soc Med 16:174, 1962 practice: A group research project. Can Fam Physician 16. Bergen BJ, Weiss RJ, Sanborn GJ, et al: Experts and 15:63, 1969 clients: The problem of structural strain in psychiatric con­ 4. Riley GJ, W ille CR, Haggerty RJ: A study of fam ily sultations. Dis Nerv Syst 31:396, 1970 medicine in upstate New York. JAMA 208:2307, 1969 17. Shorten SM, Anderson OW: The physician referral 5. Greenhill S, Kolotyluk K: The hospital bed and the process: A theoretical perspective. Health Serv Res 6:39, general practitioner. Can Med Assoc J 92:67, 1965 1971 6. Clute KF: The General Practitioner: A Study of Med­ 18. Weed LL: Your Health Care and How to Manage it. ical Education and Practice in Ontario and Nova Scotia. To­ Essex Junction, Vermont, Essex Publishing Inc, 1975 ronto, University of Toronto Press, 1963 19. Signall KA: An interactional method of teaching 7. The College of Family Physicians of Canada: Edu­ consultation. Community Men Health J 10:205, 1974 cational Objectives for Certification in Family Medicine. 20. Ways PO, Loftus G, Jones J M : Focal problem teach­ Willowdale, Ontario, 1973 ing in medical education. J Med Educ 48:565, 1973

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