When to make a referral?

Referrals are a tough topic in primary care.

Two phone calls today reflect some of these issues:

"JMR .. patient on phone .. wants referral to a back doctor .. ok to make the referral?"

"uhh .. put her through please"

I want to talk with the patient so that I can understand why she wants the referral and why she thinks this is something that requires a specialist.  Clearly I am not a back doctor or a front doctor or a foot doctor … but I may be able to help people with problems of these parts.  Turns out that the chiropractor hasn't helped much despite thrice-weekly treatments for 3 months.  She has low back pain.  No symptoms of anything bad.

What to do? 

  • I can require that she come in to the office .. but then I am being the "gatekeeper."
  • I can just refer her to the orthopoaedist .. but then I am making an inappropriate referral.
  • I can refer her to physical therapy (which is what would most likely occur as a result of a visit with me or the orthopoaedist).

    Hmm … which is the right answer?

Ok .. number two is harder.

I care for many physicians in my practice.   Caring for other physicians is tough.   Our office got a phone call a few weeks ago from a specialist about a referral that they needed from us so that they could see a patient who was there for an office visit that day.  The patient never called me .. never asked if I thought that a referral was necessary .. and never asked our office for a referral.  By making the appointment directly with the specialist – a message is sent to the primary care physician that our training and opinion is inferior to the patient's own ability to triage the situation.  For this scenario (I won't go into the details) I am certain that I would have been able to provide the service that the patient was looking for myself.    grrr…

4 thoughts on “When to make a referral?

  1. The only way to get past this issue is for health plans to institute a modest economic disincentive for patients who insist upon seeing specialists for common problems that can be managed by primary care physicians. Let the patient see the specialist for common low back pain, but make it cost a co-payment of $50 to $100. Then you’ll see how many people still want that referral. The media has programmed the public to “demand the best.” To most, it means “a specialist.”

  2. This is a huge issue. I see patients that want a specialist for each of their issues, even though I could handle most appropriately. My health plan now charges US$25 for specialist visits, and 0 for primary care visits.


  3. To deny referral should be made a felonyu. Medicine must free itself from the cancer of the bottom line and remember its basic tennent :Do no Harm. Less profit is better.

    Personally I am for lower fees, higher taxes and more government involvement to protect us from careless and speedy treatments.

  4. From a patient’s point of view – my family doctor is entirely competent to handle most things. However, his staff is much less competent to deal with things beyond a common cold. Other than the 90 seconds that I spend with the doctor, everyone I’m in contact with at that office is unprepared to deal with complex problems. For instance, the appointment scheduler doesn’t understand that some problems need a longer block of time. The nurse who does the intake interview doesn’t know what questions to ask, then the doctor tries to assess the situation with limited time and info. I’m trying to explain the problem; he’s frustrated because he doesn’t have the correct data points to diagnose.

    A visit to the doctors office takes approximately 90 minutes – I see the doctor for maybe 2 minutes. That means that means nearly all of my care in that office is with staff who are great at common issues, but iffy on uncommon ones. I adore my doctor; he is excellent. This is not a criticism of him, but if I have anything uncommon I skip the gatekeeper visit and see the specialist.

    If you want to understand why patients demand referrals take a look at the entire experience of visiting a specialist versus a family doctor.

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