Family physicians possess the knowledge and skills to handle 95 percent of the problems presented at patient visits, but at least once per day, on average, a patient's condition requires a referral.¹

Referrals and consultations are an important part of patient care, but they present numerous challenges: Will the consulting physician treat only the problem in question? Will he or she notify you of all test results and treatment plans? Will your patient be sent back to you for future care? Communication with your patient and with the consulting physician is key to ensuring that these things happen. This article discusses how to make referrals and consultations run smoothly for everyone involved.

Starting on the right foot

Just as too many cooks in the kitchen can spoil the broth, too many physicians caring for one patient can result in confusion, duplication of services or even serious medical errors. According to data from HowsYourHealth.org, a health assessment Web site developed by Dartmouth Medical School, about 40 percent of Americans between the ages of 50 to 69 see more than one physician, and about one-quarter of those patients say they do not know who is managing their care. This makes referrals and consultations a pressing concern. Though you can't always control whether your patients see other doctors, you can do your part to make referrals and consultations more hassle-free.

According to John Wasson, MD, professor of community and family medicine at Dartmouth Medical School, cofounder of HowsYourHealth.org and faculty member for the Institute for Healthcare Improvement, the key to successful referrals is making sure the right people do the right things at the right times for the right patients. “The specialist and the primary care physician need to talk to each other, trust each other and know who's going to do what,” Wasson says.

Andrew Eisenberg, MD, MHA, a member of the AAFP Commission on Practice Enhancement, agrees that clarifying roles and boundaries with consultants is essential. He often calls consultants to explain up front what he needs from them, but he also recommends sending written instructions via a standardized form. “The form should say, in essence: ‘I'm asking for a referral or consultation on this patient. I'm doing this because you have knowledge in this particular area that is needed for better care of my patient. I appreciate your assistance with this limited problem. If you have suggestions, concerns or comments, please forward those to me. I will make the decision about further care.’”

A sample consultation/referral request form is shown below. The form, updated from one previously published in FPM, allows you to indicate exactly what you need from the consultant and how you wish to be notified about the patient's progress. It also implies that the consultant is not to go beyond what you requested.

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The form is divided into three parts. The first section specifies whether the request is for a consultation or a referral (see below for clarification of the distinction between the two terms). The second section is for pertinent patient information – anything the consultant needs to know before beginning to work with your patient – and your final instructions. The third section is for the consultant to report his or her findings before returning the form to you. The form is available as both a PDF document, which you can print, complete by hand and easily fax back and forth, and as a Microsoft Word file, which you can complete electronically and e-mail to consultants. If you use an electronic health record system (EHR), you may be able to create a similar form within your system, and much of the data could be input automatically.

William Soper, MD, MBA, member of a two-physician practice in Kansas City, Mo., and member of the FPM Board of Editors, developed a similar form for his practice. He recommends keeping your form as simple as possible to save time. “The less each doctor has to read and complete, the better,” he says.

A consultation/referral request form can be immensely helpful not only for the consultant but also for you, as long as the consultant completes and returns it promptly. If this doesn't happen, contact the consultant to discuss the matter. Soper finds that a direct phone call to the consultant, not the office assistant, will produce the best results.

“Most consultants will be embarrassed by you having to call them,” he says. “Hopefully, after it happens a couple of times, they will have you high enough on their radar that they will automatically follow up the next time.”

Involving patients and technology

Some physicians opt for other methods of transferring information to consultants. For example, some prefer to shift more responsibility to their patients.

Rick Madden, MD, also a member of the AAFP Commission on Practice Enhancement, practices in Belen, N.M., as part of a large hospital system. Though many of his referrals are to physicians within his organization, good communication is still a priority. Madden chooses to write the purpose of the referral and any accompanying instructions on his prescription pad, and then he gives it to the patient to take to the visit. He likes this system for two reasons. First, it's convenient. “The easiest, handiest thing for me is to just write the referral instructions on a prescription pad. It's right there in my pocket. I don't have to hunt for a form.” Second, he believes it empowers patients to become more involved in their care. “If the patient hands the paper to the physician, the patient is directly involved and becomes more aware of how the system works,” he explains.

Erica Swegler, MD, a family physician in Keller, Texas, and a member of the AAFP Commission on Quality, employs a similar system. She provides her patients with all relevant information, including copies of lab work and diagnostic testing, to take with them to their visits. “We've found that when we fax this information to the specialist's office in advance of the patient's visit, it gets lost because the other office doesn't yet have a chart for the patient.” Swegler feels more confident that the information will reach its intended destination when the patient carries it in hand.

“It's critical that patients arrive at the specialist's office with all the rationale for why you sent them. They should be able to communicate why they're actually there,” Swegler says.

Another strategy, communicating electronically with consultants, also has many advantages. Practice management consultant Judy Capko advocates using the Internet as much as possible to relay information to consulting physicians. E-mailing or e-faxing directly from your EHR can be more efficient than wondering whether a traditional fax really went through and whether it made it to the right person, she explains. “When you communicate online, it's much easier to track the documentation trail if you need to go back and look at it. You have the data in your system, so you don't have to dig through paper.”

Regardless of which method you prefer, Capko stresses that practices must have a standard procedure for referral-related communication that clearly defines everyone's responsibilities. Consistency will make the process run more smoothly.

When consultants don't cooperate

While primary care physicians have a responsibility to make clear and appropriate hand-offs to consultants, consultants have an equally important responsibility to provide clear and timely feedback. When asked to rank their reasons for choosing a consulting physician, primary care physicians said that the quality of prior feedback from the consultant was the second most important factor, just behind personal knowledge of the other physician.¹

If the consultant is complicating matters unnecessarily by neglecting to follow up with you about your patient's care or by referring your patient to yet another specialist without contacting you first, speak up. Both problems threaten continuity of care.

Eisenberg emphasizes that any attempt by the consulting physician to go beyond what the primary care physician requests is inappropriate. “When I call for a referral or consultation, it is to address the problem at hand. The consulting physician should not take further action without my approval.”

Madden describes how secondary referrals can cause problems. “There have been occasions when I've sent a patient to one specialist, and that specialist has sent the patient to another specialist without calling or asking my opinion. Sometimes the problem is something I could have handled,” he says. “As the primary care physician, I should at least be asked before any further referrals happen, particularly if the problem is in my area.”

Even when a secondary referral is appropriate, there can still be problems. The first consultant will often fail to notify the primary care physician, and the second consultant will often communicate only with the first consultant. “That is a system problem that the second specialist should recognize,” he says. “They need to ask the patient, ‘Who is your primary doctor?’”

In these situations, communication with your patients becomes crucial. “I've tried to educate patients that if they are sent to another doctor, they should ask him or her to send me a letter. If I see the patient and I find out they've been to a second specialist referred by the first specialist, I'll say, ‘The next time you see that doctor, please ask him to send me a letter,’” Madden says. When necessary, he will pick up the phone and contact the second specialist to obtain the information he needs to care for his patient.

Establishing a rapport with specialists can lessen these problems and make the referral process easier. “I base my referral patterns on the specialists who send my patients back, don't refer them elsewhere and communicate with me directly,” Eisenberg says. It only takes one bad experience to eliminate a physician from his referral list.

Eisenberg also draws the line if he finds that his referred patients are seeing a midlevel provider rather than the consulting physician. Swegler agrees that this is objectionable. “If I send a patient for a specialty consultation, my expectation is that the opinion and the consultation are from the physician. I make that abundantly clear. We've had a couple instances where patients saw a PA at their initial office visit, and we called the specialist to say that was not acceptable.”

For some physicians, especially those in rural areas, these criteria may be unrealistic. Your practice situation will help you decide what works best for you.

Keeping patients in mind

When referring patients to specialists, the occasional ego or turf battle can ensue. Don't let these distract you from the most important part of the referral process: your patients.

Capko recommends checking in with patients regularly about their experiences with specialists and their offices. “Even though you think someone is a great clinician, you won't know for sure whether that doctor or that practice is meeting patients' needs unless you ask your patients directly,” she says.

Additionally, Capko emphasizes the need for a system to track referrals. For example, some practices use a tickler system to remind them which patients were sent to which physicians on which date. Saving a copy of the consultation/referral form shown above would be an easy way to do this. After a certain number of days, if the practice hasn't seen a report from the consulting physician, the system reminds them to check whether the patient made the appointment and followed through. Too often, she says, practices use the consultant's report as the tickler. “But what if the report doesn't come in? What if the patient didn't go? You need to have systems in place that filter these patients back into the office.”

It's also helpful to make sure your patients have realistic expectations about the referral process. Post your referral policy. Share your knowledge of the specialist with your patients. Explain what they can anticipate both from the physician and from his or her office. Let patients know they can contact you if they have any questions or concerns.

Finally, remember that just because you haven't initiated a referral doesn't mean your patients aren't seeing other doctors. With PPOs, many patients enjoy the freedom of choosing which physician to see and when, without needing a referral. Wasson stresses the importance of asking patients two questions at every visit: 1) Are you seeing another physician? and 2) Are your visits with the other physician of value to you? Together, you can decide whether seeing another physician is necessary.

Making referrals work for you

Referrals can cause unnecessary headaches for you, your patients and your practice. Learning to manage them efficiently and effectively can reduce these problems and curb the fragmentation of care many patients experience when they bounce back and forth between physicians. A standardized form of communication, such as a referral request form, will help consultants provide appropriate care for your patients and keep you in the loop, making the process run smoothly for everyone.