Improving the FP-specialist referral process

Last week, I attended a joint conference of the Canadian Medical Association’s specialty and family practice (FP) representatives. This was the second year of the joint meeting and the theme was the same: How to improve the referral process between specialists and FPs.

The main task was to identify problems with the current system. There was no shortage of suggestions/complaints.

From the specialists:

Inadequate information in the referral letter (e.g. no medical history or list of medications)

No clear clinical question to be answered by the specialist

Tests results not included in the referral letter

Illegible writing

Inappropriate referral (to the wrong specialist)

No indication as the urgency of the problem

Referral initiated too late in the course of the patient’s illness

Treatment recommendations or requests for further testing not carried out (“I don’t think anyone read the consultation letter I sent back.”)

FP not willing to manage chronic conditions, even with specific recommendations in my consultation letter

And just so specialists don’t get too smug, the FPs shot back with:

Don’t know if the specialist has received my referral letter

Not clear if the specialist will contact the patient with an appointment, or whether I should do it

Don’t know how long the wait times are

Don’t know what tests the specialist wants done ahead of time

Delay in receiving consultation report

Clinical question not answered in consultation report

Not clear who is responsible for providing ongoing care for chronic conditions

Don’t know what each specialist’s sub-specialty interests are

Some comments that came up during general discussion were interesting:

Calling the process a “referral” implies the necessity of a face-to-face visit between specialist and patient. We should consider the process a “consultation” which suggests an exchange of information between FP and specialist. This could be accomplished by phone, email or hallway conversation.

Funding mechanisms (such as fee-for-visit) limit solutions. Several practitioners who worked under alternate funding programs talked about using telehealth, phone calls and email to great advantage. This is (financially) unattractive for fee-for-visit specialists, unless their jurisdiction has fee codes covering these options.

Some of the solutions aimed to improve the content and quality of the referral letter using standardized templates and checklists. Our clinic’s microhematuria algorithm is an example of this with its request for specific testing to be completed before the urologic consultation.

I’m most encouraged by efforts that go beyond just the fine-tuning of the current process. Some people are trying to make referrals more appropriate, or even render them unnecessary.

For example, the Saskatchewan Surgical Initiative’s back pain pathway trains FPs on how to better distinguish surgical and nonsurgical candidates. Patients who are unlikely to benefit from surgery can be immediately directed to the appropriate treatment (physiotherapy, exercise) rather than languishing on a surgeon’s wait list, only to be eventually given the same advice.

A clinic in Northwest Territories is looking at common reasons for specialist referral, and then targeting FP professional development around those topics. Increased FP expertise and confidence for treating common “specialty” conditions will reduce specialist referral rates and allow patients more prompt treatment.

The patient referral process is the key interface between FPs and specialists, and as with many of the “hand-offs” in healthcare, it’s fraught with problems. After attending this conference, the two biggest problems I see are these:

There’s no feedback system to educate either FPs or specialists as to the quality of their contribution to the referral process. In the current system, a FP can send me a referral letter with inadequate clinical information, yet will get a complete consultation report in return. From his/her point of view, the referral letter got exactly the intended result, so why should they change their behaviour? As one of my partners is fond of saying, “What you permit, you promote”! Of course, it works both ways; if I don’t answer the FPs clinical question or help the patient with their problem, I will only know about it if the patient is referred back to me for further assessment. Neither of us can improve unless we’re shown – in an objective and constructive way – where we need to improve. I know that peer feedback would be a strong incentive for me to provide a better service.

An even deeper problem is lack of patient involvement in improving the referral process. The FP/specialist conference clearly focused on perceived physician needs. As healthcare workers, we often flatter ourselves that we can represent our patients’ interests in these matters. My experience in working with patient representatives on similar groups is that they bring a perspective that we lack. As such, I recognize that I can’t predict what a patient would add to the discussion. But, I’ll take a stab at it anyway:

No clear clinical question? I’ll tell you the question, because I’m the one with the problem.

Not enough medical history on the referral? Let me fill that out for you.

I’m being referred for pain in my knee. You “don’t do knees”? Well, then you better make that crystal clear right away, because I don’t want to wait 9 months to hear it.

I drove 4 hours and stayed in a hotel overnight to have a 10-minute discussion with you. Why couldn’t we do that over the phone? Because you get paid more if I turn up in person!? If I knew that ahead of time, I would have made the phone call, paid you the difference and still come out ahead.

Maybe next year we can get some input from the people who are truly affected by a dysfunctional referral process.