American College of Physicians: Internal Medicine — Doctors for Adults ®


Learning the etiquette of referrals

From the May 1997 ACP Observer, copyright 1997 by the American College of Physicians.

By Deborah Gesensway and Jennifer Fisher Wilson

When it comes to taking care of patients with major depression, a psychiatrist said he thinks internists should refer only complicated or refractory cases to a specialist. And when treating diabetes, a generalist and subspecialist agreed that general internists should keep up on cutting-edge care, but defer to a specialist's expertise when they are not making progress with a patient.

Those conclusions came during a series of Annual Session panels on "shared responsibility" that explored the intersection between general internal medicine and subspecialties for such diseases as congestive heart failure, diabetes, arthritis and HIV/AIDS. A new feature of Annual Session, the multispecialty panels were meant to explore how care can best be shared primarily to improve patient care, but also to foster collegiality among physicians.

"We need to focus on creating solutions so we can work together better," said ACP Regent Oscar E. Edwards, FACP, during one of the courses on general issues such as the etiquette of referring patients. "Better communication between generalists and specialists ensures good patient outcomes." Dr. Edwards cited figures estimating that 15 million referrals are made to specialists each year.

According to Dr. Edwards, the idea for the "shared responsibility" sessions grew out of several summits the College cosponsored in the last few years with the Council of Subspecialty Societies. These summits explored ways general and subspecialty internists can more efficiently and effectively share in a patient's care. "The idea was not to say when should [a referral or request for a consultation] occur, but how," Dr. Edwards said.


During a panel exploring issues related to diagnosing and treating depression, Ned Cassem, MD, chief of psychiatry at Boston's Massachusetts General Hospital, said that he would like internists to become confident enough in diagnosing and managing depression that they refer only complicated or refractory cases. Given the arsenal of easy-to-administer antidepressants available and strong evidence that they can effectively control depression, Dr. Cassem said, primary care physicians are more equipped than ever to be primary caregivers for depressed patients.

However, a specialist is more appropriate for a patient if "the severity was terrible and the patient was suicidal, the patient was manic, or the patient had failed a couple of drug trials," said Dr. Cassem. "If the person is hard to get along with, you can send him to me too."

If general internists are to take on the lion's share of caring for depressed patients, a number of holes in internists' knowledge base need to be plugged, the panel concluded. Perhaps even more importantly, internists need to change their attitude that they can diagnose depression only after ruling out a whole range of other possible causes of the patient's symptoms.

For example, the panel worked through a case study about a 61-year-old man who, during a regularly scheduled follow-up appointment for his hypertension, noted that lately he had been feeling depressed and fatigued, was having difficulty getting to sleep and trouble concentrating at work.

"I would like to do more medical evaluation, repeat lab studies," said James Richter, FACP, an internist colleague of Dr. Cassem's from Massachusetts General, who admitted that he was probably thinking too much like an internist. "Depression is high on my list, but I haven't come to a diagnosis of depression."

Dr. Cassem, however, said he thought the case presented enough information for an internist to declare this patient clinically depressed and to start him on antidepressant therapy even while continuing his work-up to look for other causes. "When you meet the criteria, you have the disease," Dr. Cassem said.

After adding depression to the list of working diagnoses, however, Dr. Richter asked, "how do I decide if it's dangerous, or severe? Do I want to treat him myself?"

Dr. Cassem replied that most strategies for determining severity of depression involve looking at the patient's ability to function and always asking, "Do you feel helpless, hopeless, worthless? Are you down on yourself?" Hopelessness, Dr. Cassem said, is a sign that could signal suicide risk.

It is helpful when physicians know the risk factors for suicide, which include having made a prior attempt, using alcohol, being either an adolescent or over age 50, living alone, having a chronic illness or some co-morbid psychiatric condition, having a family history of suicide and having an organized plan for how to go through with it. Discerning the severity of a person's depression can be difficult. "We've all been fooled at some time or another," Dr. Cassem said.

Patients should remain on antidepressants, he said, for at least six months, even if they appear to be in remission sooner. And patients who have had a previous episode of depression should remain on a therapeutic level of the drug for at least a year. If it is the patient's third episode, Dr. Cassem said, physicians should consider keeping the patient on medication for at least five years or even for life.

"This is a disease that recurs," Dr. Cassem said. "If [the patient] never had an episode before, he has a 50% chance that he's going to have a second depressive episode. If he's had a prior episode, then he has an 80-90% chance [of] a third depressive episode."

One way to help maintain a state of remission, Dr. Cassem said, is to add psychotherapy to the treatment. Two types of counseling have shown to be efficacious in major depressive illness: cognitive/behavioral therapies and interpersonal therapy. "Psychotherapy, once the person is less disabled by the depression, has a more powerful role in maintenance—that is, keeping the person in remission—than the drugs do alone," Dr. Cassem said.

Dr. Cassem recommended that internists become familiar with one or two of the antidepressants and learn how to prescribe them. Internists can select a drug based on its usual side effects, start with low doses, monitor its effects and then increase the dose, add some other drug that augments the antidepressant's effect or change to an entirely different drug. None of the antidepressants—either the classic trycyclics or the newer selective serotonin reuptake inhibitors—appear to be any more effective than any other, he said.


In terms of caring for patients with diabetes—which was explored during another "shared responsibility" panel—experts agreed that generalists and subspecialists should work together when generalists feel their expertise has reached the limit, explained Dr. Edwards, a general internist in Norfolk, Va. "It's my responsibility to keep up with what's available," and not send patients to subspecialists unnecessarily, he said.

Internists can handle diabetic patients' needs such as eye tests, foot care and diet compliance as well as can a diabetologist, said Jay S. Skyler, FACP, a diabetologist and chair of the Council of Subspecialty Societies. "It's only when generalists get stuck and are not making progress that [they should] come to me with a referral," he said, noting that only about 8% of diabetes patients see a specialist.

Dr. Skyler warned, however, that generalists have a high rate of error when screening for dilated eyes—which, when interpreted appropriately, can reduce blindness. While diabetologists do somewhat better, retinal specialists are the only doctors who have a low rate of error in interpreting test results, Dr. Skyler said. If retinal specialists are unavailable, or if patients' health insurance does not cover the referral, he recommended ophthalmologists as the next best choice to administer and interpret the test.

Generalists may also find it difficult to help with diet noncompliance, because many physicians are not trained to provide nutrition education. Instead of calling a subspecialist for assistance, Dr. Skyler suggested that physicians contact a dietitian or diabetes nurse. Only send the patient to a subspecialist "if the patient is still out of control," he said.

Once a referral has been made, who is responsible for patient's care? Dr. Edwards concluded that until a care plan is laid out, both the generalist and subspecialist share responsibility.

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