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Getting past the problems of patient referrals

Culprits include generalists who don't send test results and consultant who never return patients

From the March 1998 ACP Observer, copyright 1998 by the American College of Physicians.

By Maureen Glabman

When talking about the topic of physician referrals, Ian H. Leverton, MD, likes to tell the story of a patient whose general internist sent him to a gastroenterologist with a one-word note: "Abdomen?" Stymied, the gastroenterologist sent the patient back to the referring physician with a similarly curt note: "Abdomen present."

Dr. Leverton, former medical director of Kaiser Permanente in Oakland, Calif., uses the story to illustrate the problems that plague the referral process. From basic communications problems to the more delicate issue of who manages patients after a trip to the consultant, the referral process is often a balancing act for primary care physicians and specialists alike.

A major part of the problem has to do with expectations that are never met. Consultants receiving referrals expect patients to arrive with chart notes and test data. In turn, the referring physician expects the consultant to offer an opinion promptly, in writing or otherwise. And finally—and perhaps most importantly—the consulted doctor is expected to return the patient to the referring physician.

Managed care can add more problems. Physicians must often refer patients to consultants listed in a managed care directory whom they don't know or whose judgment they may not trust.

Here are common problems that occur in many of the 80 million referrals physicians make to one another each year (a figure from the Robert Wood Johnson Foundation)—and solutions suggested by some physicians and institutions:

Problem: Consulting physicians must resort to guesswork when referred patients arrive without test results or any notes from the referring physician.

"Once or twice a month, a patient presents without documents," said Philadelphia gastroenterologist, Harris R. Clearfield, FACP. "It's particularly problematic with older patients who have multiple medical problems. It's important to know what the referring physician has in mind."

Dr. Clearfield added that managed care is worsening this problem. "If a patient is authorized for only one visit to a specialist, and the patient arrives without X-rays, lab results and a note from the primary, a second visit is essential," he said.

Solution: Primary care physicians can have office personnel responsible for referrals send a complaint form and recent tests and notes to consultants. Another option is to have patients take their records with them when they see the consulting physician.

Generalists should be warned, however, that specialists sometimes resent getting an order for a procedure without talking to the primary care physician first. "My chronic problem is internists who write an order for a chest tube without having the courtesy to call me," said Miami thoracic surgeon Richard Rubinson, MD. "It's like they are requesting a Midas muffler. They're calling me in to do a procedure without inviting me to bring my thought process to the problem."

Problem: Both the specialist and primary care physician think it is their job to manage patients after a consult.

Solution: To most primary care physicians, their relationship with consultants is clear. "A consultant's job is to send my patient back to me with my question answered and a plan," said David Slawson, MD, an associate professor of family medicine at the University of Virginia Health Science Center. Ultimately, after a patient is seen by a referring doctor, the decision-making responsibility rests with the primary physician and the patient, not consultants. Specialists should return patients to primary physicians when disease is cured, when the patient is stable, when the specialist has nothing left to contribute, or when it is clear the primary care doctor can handle the case, said Farrin A. Manian, FACP, an epidemiologist at St. John's Mercy Hospital in St. Louis.

Managed care, however, is complicating this relationship. While health plans have typically made primary care physicians responsible for overall patient care, roles are changing. One concept known as "principal care" allows specialists such as oncologists to serve as gatekeepers for certain patients, said ACP Regent Oscar E. Edwards, FACP, a general internist in Norfolk, Va. "A number of studies have shown certain patients get better and more effective care if a specialist is the primary," Dr. Edwards said.

Problem: Patients sent to specialists at academic medical centers vanish.

Solution: When specialists refer a primary care physician's patient to another specialist, the consensus is that they should inform the referring doctor and send a report within three days. If the situation is urgent—surgery is required, for example—the specialist should call the generalist immediately.

If the patient needs surgery and the consultant is not a surgeon, the advice is to let the generalist help choose the surgeon. "It can alienate the primary care physician because the other physician may not have a good relationship with my choice of surgeon," said Philadelphia gastroenterologist Dr. Clearfield. "The choice should be a combined decision."

Problem: The specialist admits and discharges a patient to the hospital without notifying the primary care physician.

Solution: To solve exactly this type of problem, Bowman Gray School of Medicine in Winston-Salem, N.C., created a telephone hot line in 1989 to update community physicians. The school's Physicians Access Line (PAL) is a toll-free number that rural physicians can call to speak to a faculty member 24 hours a day. In eight years, the system has logged 605,000 calls. The majority of calls are for discussion of patient transfer or an outpatient appointment, for new patient consults, for bouncing a management plan off a specialist, or for updates on a case.

"Ninety-three percent of physicians in 26 counties have used the service at least once," said Eugene Adcock, MD, a Winston-Salem pediatrician who helps direct Physicians Access Line. "There are lots of 800 programs out there for patients to find doctors but not many for doctors to find and speak to doctors."

Problem: Specialists send follow-up reports to referring physicians late-or not at all.

Solution: To address this problem, Kaiser Permanente has created contractual agreements in certain parts of the country with consultants who are not on staff. These contracts specify how quickly consultants must see referred patients and how soon after the visit they need to get a report to the referring physician.

Referrals betweeen staff physicians tend to be verbal, but there are referral and response forms as well, said Dr. Leverton, Kaiser's director of interregional consultants. Consultants are expected to respond within 24 hours of seeing the patient, he said.

"Communication between physicians was assumed to be a gentlemen's agreement," said Dr. Leverton. "We have slowly moved toward contract language that demands the return of information about patient care."

While Prudential's Eastern States division has no formal protocols for communication, complaints are pursued. Lax physicians could eventually be disenrolled from the plan, said Esther R. Nash, ACP Member, Prudential's senior medical director for Eastern states.

Primary care physicians frustrated with delays in getting reports from consultants might consider setting up a tickler file to ensure a medical record is not filed again until test results or reports are returned, according to Denise Bisaillon, director of training and development for Harvard System's Risk Management Foundation, a group of more than 20 hospitals in the Boston area.

When gentle reminders don't work, Connecticut internist Brendan Montano, MD, suggested tougher measures. "If consultants fail to send the patient back after consultation—a cardinal sin—or if they are poor in follow-up reports, we stop referring to them," he said.

Problem: Primary care physicians don't call for consultations early enough, jeopardizing patient care.

Solution: This is clearly a judgment call. Some doctors are embarrassed to pass along a patient before exhausting considerable measures for fear of appearing unknowledgeable or to keep costs down. "I try not to send patients to consultants too quickly," said Dr. Montano. "If you do not treat diseases in the primary care setting, you're costing the system too much. It's a balance."

But keeping that balance can be difficult. Dr. Manian, the epidemiologist at St. John's Mercy Medical Center in St. Louis, related the case of a patient with a persistent high fever who had been in a malaria zone in Africa. The patient had been seen by his HMO internist three times and had tried several antibiotics. After three weeks of trials with no improvement, the patient went on his own to a hospital emergency room.

When the emergency room phoned the internist, he was reluctant to have the patient admitted. "In HMOs, where you're trying to keep costs to a minimum, some doctors drag cases on longer than they should," Dr. Manian said. "Clearly, this patient, who had one of the worst forms of malaria, was bouncing around on the wrong antibiotics."

How can primary care physicians know when it's time to bring in a consultant? According to Dr. Manian, there are a few signs:

  • A case is unusual and the primary physician has not seen it frequently;
  • The primary care physician repeatedly requests curbside consultations; and
  • The primary care physician has exhausted all available diagnostic tools.

Maureen Glabman is a Miami-based writer who specializes in health care.


How to steer clear of trouble with curbside consults

Can you give me your opinion on a case? That is something that many internists have heard countless times in doctor's lounges, while walking to their cars, on the telephone and even through e-mail. While the curbside consult is an everyday part of some physicians' lives, it may not always be the safest thing to do.

Some fear that giving advice in a curbside consult may result in incorrect advice. "In five minutes, I can't possibly understand the dynamics of a case and give a reasoned answer," said Philadelphia gastroenterologist, Harris R. Clearfield, FACP.

Even more importantly, however, are the legal implications of giving off-the-cuff advice. Curbside consultants can potentially be dragged into a malpractice suit if the physician who asked for advice names the consultant in the patient's chart or mentions the consultant's name in conversations with the patient. Similarly, if a physician or attorney refers to a curbside consult during a deposition, the consulting physician can potentially be named as a co-defendant.

Physicians are left balancing the threat of litigation with their duty to help out colleagues. "How does one gracefully excuse himself," asked Miami thoracic surgeon, Richard Rubinson, MD. "What am I supposed to say, 'My lawyer tells me not to talk to you?' " This is what collegiality is all about. It's very flattering when a colleague asks your opinion."

Besides, curbside consults can be a good source of new business. "I get three or four sets of X-rays a week from physicians who ask what I would do," said New York transplant surgeon James Piper, MD. "There's never a bill. I know if I can develop a rapport, I'm the one they'll call when they need a paid consultant."

What's a consultant to do? Physicians handing out impromptu advice should at the very least consider these questions, which the courts have used to define legal involvement in a patient's care:

  • Has the doctor met or examined the patient?
  • Has the doctor reviewed the patient's chart?
  • Was the physician formally engaged to act as a consultant?
  • Was the patient formally referred to the doctor?
  • Was the physician engaged in conduct that can support that inference that she consented to treat the patient?
  • Was the physician a designated on-call physician for a health plan that provides coverage to the patient, or was she on call in a situation where a specific contractual relationship is defined?

Legal experts say that merely answering a colleague's question does not necessarily engender a legal physician-patient relationship and that informal interchange between colleagues is often educational. Experts also point out, however, that consultants should not give specific advice about a patient whom they have not examined.

If there is no way to tactfully dismiss an inquiring colleague, experts suggest that consultants emphasize that they are merely responding to a hypothetical situation, and that remarks are not meant for a specific patient. And just to be safe, consultants are advised to keep a record of the interaction.

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