Referring to other medical specialists

Naomi Johnson

3/12/2019 3:48:25 PM

Dr Chris Bollen reflects on his research to address ongoing issues hindering the referral process, and on the importance of getting it right.

Referral to other specialists
The RACGP has released a new resource: ‘Referring to other medical specialists: A guide for ensuring good referral outcomes for your patients’.

‘We’ve got to look at this as professional pride, brand and for junior doctors: Why would [they] want to come to general practice if that’s the standard?’
That is Adelaide GP Dr Chris Bollen on the importance of good-quality referrals from GPs to other medical specialists.
‘If I write a bad referral letter, whether it’s for outpatients, the ED or a specialist, that’s my brand [and] that’s my practice’s brand – peer respect is lost,’ he told newsGP.
In 2014, Dr Chris Bollen reviewed 670 referral letters sent to major hospitals in Adelaide.
His study found that while most referrals were issued appropriately, concerns reported by other medical specialists included duplicate referrals being sent to multiple hospitals, and lack of detail or uncertain information making it difficult to triage.
At the time of his research, Dr Bollen was working as the Director of General Practice Training at the Queen Elizabeth Hospital.
One year later, and after 12 years in the role, his position was made redundant.
‘They basically said, “Look, we don’t need GPs in public hospitals. And if anyone thinks that we do then the Commonwealth should be paying”,’ he said.

Dr Bollen believes the shift away from working closer with other medical specialists has done a disservice to the referral process.
‘It’s one of the things that our whole medical system is lacking now. We don’t actually have opportunities to sit and chat with our peers from different disciplines of medicine,’ he said.
‘General practice is pretty isolated. Most GPs work in their practices [and] they’re lucky if they see each other during the day and occasionally they go to education sessions and see a specialist.
‘If you don’t have relationships with people, you don’t tend to know what matters to them, you don’t tend to [know] the things they want to see in referrals.
‘[Knowing] what’s happening in each others’ worlds makes a difference.’
Dr Bollen attended the Central Adelaide Local Health Network GP networking event at the Royal Adelaide Hospital last week, which focused on the topics of referrals, discharges and communications between medical specialists.
‘The big message for everyone [was] that if you’ve got a rubbish referral letter going to a specialist and your patient’s depending on either private or public healthcare, then you are doing your patient a disservice,’ he said.
‘If you’ve put minimal information [in the referral], then the specialist cannot make a decision on how timely the appointment needs to be.’
Dr Bollen also touched on issues with continuity of care affecting referrals. 
‘[In general practice] there are different models of care. The old style of having a single doctor, single practice to go to with all of your needs seems to be quite variable around the country,’ he said.
‘Many of our patients, especially younger patients, [are] less likely to have a regular GP.
‘I’m going to struggle to give my best-quality referral on the first time I ever see you because I’m not going to get all of the required information. You may not remember all of your past medical history.
‘Regular GPs know their patients and tend to have a lot of information about them, so the opportunity to make a good-quality referral is much greater than if you are asking people very transactionally.’

Dr Chris Bollen believes the shift away from working closer with other medical specialists has done a disservice to the referral process.

When asked about the idea of indefinite referrals – where a GP essentially hands over ongoing care to another medical specialist – Dr Bollen said ‘certainly there’s lots of discussion about indefinite versus yearly referrals’.
‘I’m in two minds on this. Our specialist colleagues [are] pretty focused on a single-disease, single-organ approach to life,’ he explained.
‘If we take general practice to be the holistic approach, we’ve got the coordination of all of our patients’ needs [and] that’s what we should be focusing on.
‘Does it matter to the other end? Do [other medical specialists] care if they don’t get a medication update?
‘Because if I saw you every year for your referral, then you get the history.’
Dr Bollen also said medical specialists should be open to feedback on referrals and their responses.
‘This is a quality improvement opportunity,’ he said.
Who and/or where to choose, associated out-of-pocket costs to patients, and how to satisfy Medicare Benefits Schedule (MBS) criteria are some of the other considerations when referring patients to other medical specialists.
The RACGP’s new Referring to other medical specialists: A guide for ensuring good referral outcomes for your patients is designed to help address these issues.
Composed by the RACGP Expert Committee – Funding and Health System Reform and including input from many other specialist medical colleges, the guide aims to support GPs in making informed decisions when providing a referral. 
‘The bottom line is, [you] want that letter faxed or secure messaged so [the other medical specialist] can make a decision about the timeliness of the appointment required and that is really important to our patients,’ Dr Bollen said.

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Prof Max Kamien, AM   4/12/2019 8:15:14 AM

A diabetologist colleague received a referral: 'Needs bariatric surgery. Please arrange'.
He replied that some further pertinent information might elevate his patient's position from the bottom of the 5 year waiting list.
The other side of the story is that some specialists and their registrars don't bother to read the good referral letter.

Dr Trevor David Hoffman   4/12/2019 11:03:16 AM

Thank you Chris for your pertinent article; Max’s example demonstrates how one arrogant and ignorant referring GP can bring all GPs into disrepute. Digitalisation of clinical notes has empowered us to write excellent referrals but GPs do not adequately record past medical history and whether it is active or inactive, so that significant details are omitted from referrals. I personally put too much crap in my e-referrals in an effort to reduce specialist and patient time being wasted and (yes) to reduce my exposure to complaints. There is a crying need for an Australian standard or guideline on e-notation and drafting e-referrals.

Dr Jo-Anne Zappia   5/12/2019 9:34:35 AM

I agree that writing a good referral letter is extremely important. What is left out is as important as what is left in eg When referring a patient to an ophthalmologist, the recipient doesn't really need to know about every cervical screen, flu shot and URTI the patient has ever had, and sometimes the wood is hidden by the trees. Referral letters ought to be relevant and concise but also clear about exactly what is wanted.