Editorials Referral and Consultation in Primary Care: Do We Understand What We’re Doing? Paul A. Nutting, MD, MSPH; Peter Franks, MD; and Carolyn M. Clancy, MD Rockville, Maryland Consultation and referral decisions by primary care phy­ also involving onlv one practice, which concluded that sicians have an enormous impact on the cost and quality' phvsicians with greater expertise had higher referral rates. of care that patients receive. Studies suggest that for each These apparently counterintuitive results are intrigu­ dollar generated by a family physician, $2 are generated ing. Does increased knowledge result in increased refer­ by the consultant physician, and $4 by the associated rals because of a better assessment of patient need? Or, hospital.1-3 does the higher referral rate simply reflect the greater Patient health is also certainly affected. Appropriate interest or curiosity' that a physician has as manifested by consultation and referral may lead to prompt diagnosis his or her increased knowledge? Alternatively, is in­ and treatment of conditions that were beyond the imme­ creased knowledge one response to a physician’s intoler­ diate expertise of the primary care physician. Inappropri­ ance of uncertainty, which is also manifested in an in­ ate referral, however, may lead to unnecessary testing and creased referral rate? Studies have suggested that a cascade of increasingly expensive, invasive, and risky physicians who are willing to tolerate more uncertainty procedures in an often futile search for diagnostic cer­ generate less intense services, including laboratory' test­ tainty.4’5 ing8 and referral.9 The finding that referral decisions vary Although studied extensively in the United King­ by problem domain is consistent with Elstein’s work dom, we know very' little about the process and results of describing physicians’ problem-solving strategies, which consultation and referral practices in the United States. indicates that physicians’ strategies are not similar across The article by Neil Caiman and his co-workers in this all content areas.10 issue6 raises interesting questions about the current con­ In their article, Caiman et al do not clearly distin­ sultation patterns in family practice. Although based on guish between consultation and referral. Though these the practices of one group of six family physicians and terms are used interchangeably by many authors, there is two nurse practitioners, the study results are consistent an important distinction based on the transfer of respon­ with data from the literature suggesting great interphv- sibility for the patient.11-13 A consultation involves an­ sician variation in frequency of consultation and referral. other physician performing a specific diagnostic or ther­ Caiman et al also found that there was substantial intra- apeutic task, without transfer of responsibility for the phy'sician variation by specialty consulted, and that this patient’s care or even for ongoing management of the variation correlated with diagnostic specificity in the re­ problem. Referral, on the other hand, involves sending a ferral letter. The results are similar to a British study,7 patient to another physician for ongoing management of a specific problem with the expectation that the patient will continue to see the original physician for coordina­ Submitted, rensed, April 30, 1992. tion of total care. The news expressed are those o f the authors and do not represent official policy o f the Consultation and referral comprise a spectrum. At Agency for Health Care Policy and Research, the US Public Health Sendee, or the one extreme is the informal “sidewalk consult.” At the Depanment o f Health and H um an Sennces. other extreme, full responsibility for coordinating patient From the Division o f Primary Care, Center for General Health Sendees, Extramural care is referred to another physician, as in the care of Research, Agency for Health Care Polin' and Research, US Public Health Service, Rocknlle, Maryland. Requests for reprints should be addressed to Paul A . Nutting, patients with end-stage renal disease. In between the M D , Dirision o f Primary Care, Center for General Health Sennces Extramural extremes are varying levels of interaction between the Research, Agency for Health Care Policy and Research, Suite 502 Executive Office Center, 2101 E Jefferson, Rocknlle, AID 20852. primarv care physician and consultant, which may result © 1992 Appleton & Lange ISSN 0094-3509 The Journal of Family Practice, Vol. 35, No. 1, 1992 21 Referral and Consultation Nutting, Franks, and Clancy in improved care for the patient, or in misunderstanding, consultation and referral is immense. This may be an duplicate testing, or inadequate care. ideal area for application of qualitative research methods. More research is needed if physicians are to under­ Dowie’s work,20 based on in-depth interviews of 65 stand the consultation and referral process and improve British general practitioners, is an important start in the their ability to effectively consult with and refer patients right direction. She demonstrated the complexity of the to specialists. In particular, research is needed in four referral decision-making process and identified three sets areas: describing the pattern of consultation and referral; of variables that drive the process: professional attributes, understanding the components of the consultation and knowledge of the health care system, and personal style. referral decision; describing the costs and outcomes of Cost and outcomes of consultation and referral. Mount­ consultation and referral; and developing better strate­ ing evidence for dramatic variation in use of high-cost gies for consultation and referral. diagnostic and therapeutic services has led to a major Consultation and referral patterns. Most of the re­ federal research initiative on outcomes and medical effec­ search on consultation and referral patterns comes from tiveness research. There is little work, however, examin­ the United Kingdom, where there is evidence of a great ing the extent to which such variations are explained by deal of variation.14-21 The most common factor that variations in referrals from primary care. The variation influences referral rates is the availability of qualified that has been observed in consultation and referral prac­ consultants.16 Little correlation has been found between tices suggests that both undcrreferral and ovcrreferral referral rates and the quality of referrals,22-24 and most erf may be prevalent. Both have significant cost and out­ the observed variation remains unexplained.14 Some ev­ comes implications. Research strategics must consider idence points to variation in consultation and referral that the appropriateness and timing of a consultation and patterns among primary care physicians in the United referral will van- by the interests and capabilities of pri­ States as well.6'11-25’26 There are few data to explain mary' care physicians, the availability of qualified consult­ variation in the United States, although patient charac­ ants, and the characteristics of the practice setting. teristics,11’1225-27 physician specialty,28-30 length of train­ Most studies of the outcomes of consultation and ing,31 and reimbursement plan1 1-28 -32 appear to be im­ referral have used intermediate outcomes, such as services portant. provided, the adequacy' of the answer to the referring phy­ The decision to consult and refer. Consultation and sician’s request, and patient satisfaction, as well as the per­ referral decisions are firmly embedded in general clinical ception of the value of the consultation and referral held by decision-making processes. There is, however, little un­ the patient, the referring physician, and the specialist. Re­ derstanding of the clinical decision processes that govern search is needed as well that examines outcomes in terms of consultation and referral practices, although some work measurable changes in health and functional status. has been done to develop theoretical models.12’18’20-30 Consultation and referral strategies. The compo­ Several authors in the United Kingdom20-33-36 and nents of the consultation and referral include the follow­ the United States31-37-38 have examined physicians’ rea­ ing: (1) the primary care physician and the patient rec­ sons for consultation and referral. These include diagno­ ognize the need for consultation and referral; (2) the sis or confirmation of diagnosis; diagnosis and treatment primary care physician communicates the reason for the recommendations; advice on treatment; treatment of a consultation and referral along with relevant clinical in­ previous condition; reassurance of patient, relative, or formation to the specialist; (3) the specialist evaluates the referring physician; specific investigations or specialty patient’s condition; (4) the specialist communicates the procedure; routine specialty examination; referring phy­ findings and recommendations to the primary care phy­ sician’s education; specific request by patient; and med­ sician; and (5) the patient, primary' care physician, and ical-legal reasons. specialist understand their responsibilities for continuing The results of Caiman et al suggest the need for a care.26-37 Problems in the consultation and referral pro­ complex model to account for the variability' of the cess, however, have been identified at every step,26 many decision-making process in consultation and referral. Ad­ of them attributed to failures in communication and ditional