The referral—consultation process is a cornerstone of patient-centred care. Good communication between referring physicians, consultants and patients is crucial. Both referring and consulting physicians have a professional and ethical responsibility to facilitate continuity of care while supporting the patient during this process.
Common communication problems are:
- incomplete referral requests
- failure to track the appropriateness of a patient’s status on the wait list by both the referring physician and the consultant, especially if urgent care is required
- failure to communicate back to the referring physician after the consultation and to clarify roles and responsibilities of the consultant and referring physician
Should medico-legal difficulties arise, the care provided by each physician will likely be reviewed.
Referring physicians
Referring physicians can help patients understand the need for consultation by discussing the reason for the referral with the patient and obtaining the patient’s consent to be referred. To facilitate the consultation and foster appropriate triage of the request, it is important that consultation requests be clear and complete.
The referral letter may include the following:
- patient’s name, personal health number, preferred and current contact details (Note: Even if the patient has consented to email communication with the referring physician, the consulting physician should obtain consent from the patient for their own communication with the patient by email if required. Given the risks of email communication it is prudent for each physician to obtain consent in light of the processes their office employs and the technology they use.)
- date of the referral request
- reason for the referral and expectations for the consultation outcome (i.e. diagnosis, therapeutic suggestions, transfer of care etc.)
- degree of urgency
- relevant clinical information (e.g. current medications, allergies, health history, physical examination) and social information (e.g. language barriers, need for a support person)
- copies or summaries of pertinent laboratory investigations, imaging and other consultant reports
- clarity as to who will be following the patient while on a wait list and/or after the consultation
It is important that patients have a clear understanding of what signs and symptoms may herald a developing complication or worsening condition and whom to call should their condition change while waiting to be seen by the consultant. This information should be documented in the medical record.
Many Colleges have specific guidance on who should follow patients on wait lists. Some Colleges also have explicit expectations, which may also include a tracking system for consultation requests. Physicians should be knowledgeable about their College’s requirements and guidance for the referral and consultation process.
Referring physicians often feel particularly vulnerable when they cannot obtain the care they desire for their patients. The courts and the Colleges know you cannot provide care that depends on resources that do not exist. The goal is to provide reasonable care, not perfect care. To help demonstrate the reasonableness of your care, be sure to document and inform the patient of the following:
- your advice to the patient for steps they should take while they wait for their consultation (e.g. signs and symptoms to watch for that may signal a need for a reassessment or emergency visit)
- your efforts to obtain care for your patient
- your follow-up on their condition
- your communications with the consultant
Must I follow the consultant’s advice?
If you have requested advice around diagnosis and/or treatment, you should strongly consider the consultant's advice and incorporate it into the treatment plan if you deem it to be appropriate. If the clinical situation evolves or the advice does not seem appropriate, a follow-up discussion with the consultant may be warranted. When a second opinion is sought, either independently by the patient or through a referral, responsibility for the care of the patient remains with you, the treating physician. You are expected to make your own assessment and formulate your own treatment plan, and you should discuss the advice received and the final treatment plan with the patient. It is important to document the rationale for disagreeing with the consultant (when that is the case) and the patient’s informed consent to the treatment plan.
Consulting physicians
Consulting physicians should respond to the referring physician as soon as reasonably possible, indicating if they are able to see the patient within a reasonable time. Many Colleges have very specific timelines for notifying the referring physician if you are able to see their patient.
As with all physicians, specialists' acceptance of new patients is guided by ethical responsibilities, as outlined in the Canadian Medical Association Code of Ethics and Professionalism, 2 the Code of Ethics of Physicians of Québec, 3 and by professional responsibilities as stated in College policies. Such policies vary depending on the College, but generally require that specialists accept new patients on a first-come, first-served basis, free from discrimination.
College policies generally require that specialists take a number of factors into account when deciding whether to accept the referral, including:
- urgency and clinical need
- current wait times
- scope of practice and clinical competence 4
If the referral is accepted, the consultant is generally in the best position to communicate the appointment time to the patient and the referring physician. To minimize the likelihood that a deteriorating patient lingers on a wait list, it is important that consultants inform both the patient and the referring physician of the expected wait time and of the signs and symptoms of concern that should prompt a phone call or a re-evaluation of the patient’s position on the list. In addition, it is helpful for patients to be notified of any consultant office administrative requirements (i.e. expectations around cancelling an appointment, costs for no shows, etc.) as well as any medical requirements prior to attending (e.g. bowel preparations, medication adjustments, etc.).
If it is necessary to decline a referral, assist the referring physician and patient by recommending an alternative care provider, if possible.
To promote the safety of care, consider notifying the referring physician if the patient does not show up for the consultation and has not booked another appointment.
Provide a timely written report back to the referring physician. When the situation is urgent, providing this report verbally can optimize safety and timeliness of care.
The consulting report may include:
- the patient’s name
- the identity of the referring physician, and if different and known, the identity of the patient’s primary care physician
- the date of the consultation
- the purpose of the referral as understood by the consultant
- information considered, including history, physical findings and investigations
- diagnostic conclusions (definitive/provisional; differential diagnosis where appropriate)
- treatments or interventions initiated, including medications prescribed or stopped, or investigations ordered
- recommendations for follow-up and who will be providing the follow-up 5
- advice on next steps provided to the patient
If the consultation extends beyond the initial visit, provide interim reports as required. Notify both the patient and referring physician when a consultation is complete and patient care is being transferred back to the referring physician or another care provider. 6-8
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Owing to resource constraints, physicians are called upon to balance their patients’ needs with the resources available. Physicians may wish to consider the following when faced with such constraints:
- To the extent possible, place the best interests of patients first while using resources judiciously.
- Follow Choosing Wisely Canada (CWC) recommendations and evidence-based guidelines to help you streamline care, minimize strain on scarce resources, and achieve balance between needs and resource availability.
- Document the steps you took to try to resolve any resource limitations for your patient.
- Advocate professionally for additional resource availability, being mindful of respecting College policies on physician advocacy.
Remember, the courts and Colleges expect physicians to act reasonably. Care provided by doctors is judged not on a standard of perfection, but rather on the standard of reasonableness. That standard is based on the care that might reasonably be provided by a colleague in similar circumstances.
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Wait lists are a reality in the provision of healthcare. The challenge of managing waitlists contributes to the stress physicians experience from not being able to provide the quality of care they believe the patient needs.
Obligation to accept new patients:
Physicians are entitled to restrict the size of their practice, but in declining to accept new patients they must show fairness and consistency. A number of factors should be considered:
- urgency or seriousness of the patient’s medical condition
- scope of practice or clinical competence of the physician
- the imperative to avoid discrimination or the perception of discrimination
Using your clinical judgment:
- Physicians are called upon to use their clinical judgment to determine whether to accept a patient, and the degree of urgency required to assess them. Physicians should also use their judgment to determine whether a patient’s condition has changed such that they need to be moved up the wait list.
Avoiding the perception of discrimination:
- Be aware of your College’s policy addressing discrimination when accepting new patients. Most Colleges prohibit discrimination on the same grounds as under human rights legislation, such as race, ancestry, place of origin, colour, ethnic origin, citizenship, creed, sex, sexual orientation, gender identity, gender expression, age, marital status, family status or disability. Colleges may also prohibit physicians from refusing patients on other grounds specifically related to healthcare, such as medical complexity. For example, the Ontario College of Physicians and Surgeons warns against refusing patients "with complex or chronic health needs; with a history of prescribed opioids and/or psychotropic medications; requiring more time than another patient with fewer medical needs; or with an injury, medical condition, psychiatric condition or disability that may require the physician to prepare and provide additional documentation or reports." 9
- Carefully document your rationale for refusing to accept a patient and communicate it to the referring physician if applicable and, if reasonable, to the patient in order to avoid any perception of discrimination.
Managing your wait list:
Managing your wait list requires:
- effective communication between referring and consulting physicians and the patient
- clarity regarding who is the most responsible physician for following a patient on a wait list, if applicable
- using your professional judgment to monitor the wait list and move patients up the list if warranted
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It is normal for patients to feel anxious when they are told they will be on a wait list to see a specialist or to have a specific investigation or treatment. They are understandably concerned their condition will deteriorate while waiting to be seen.
When being placed on a wait list, patients should be informed of certain facts to help them monitor their situation while waiting. These include:
- the clinical situation and the reason for the referral
- the symptoms and signs that should cause them to seek further medical care (i.e. the condition is worsening or new symptoms occur)
- whom to call, where to seek care, and how urgently it should be sought
The information should be tailored to each patient and each clinical situation. This advice should include discussion of the potential side effects and monitoring requirements of any prescribed medications.
Just as when obtaining informed consent, it is important to describe the symptoms and signs of common complications and also of rare complications with a potential for serious harm. It is a good practice to confirm the patient’s understanding of the issues and address any questions. The discussion with the patient should be documented in the medical record. Discuss and document your efforts to find the resources the patient requires.
Asking the patient what concerns them the most may provide you with a clue as to how to allay some of their fears or to discuss potential alternative options. 10
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The few legal cases touching on these issues signal that the courts are willing to consider the resources available to physicians when assessing whether the standard of care was met. The courts have stated that an assessment of a physician’s clinical care is not based on a standard of perfection, but rather on the standard of care that might reasonably be applied by a colleague in similar circumstances.
The courts have been critical of conscious decisions by physicians not to offer available and appropriate tests or treatments simply to contain costs. This is differentiated from situations in which a physician simply cannot provide the treatment due to a lack of resources. While physicians have an obligation to use healthcare resources prudently, the courts have confirmed that use of appropriate testing should not be limited by cost. 10 While physicians should place the best interests of patients first when choosing tests and treatments, they should still use resources judiciously and need not overuse them as a way of avoiding possible medico-legal difficulties.
The Choosing Wisely Canada campaign offers recommendations and resources to identify unnecessary tests and treatments that consume valuable time and resources. The CWC recommendations may not be applicable in all cases, and physicians may choose to refer to relevant clinical practice guidelines to assist in decision-making and appropriate care in specific circumstances.
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Physicians owe professional and ethical duties to their patients. The CMA Code of Ethics and Professionalism underscores the fine balance physicians have when dealing with limited resources. The Code asks physicians to "consider first the well-being of the patient" but it also asks them to "promote resource stewardship." 2 The Québec Code of Ethics of Physicians instructs a physician to "be judicious in his [her] use of the resources dedicated to health care," while at the same time emphasizing that a "physician's paramount duty is to protect and promote the well-being of the persons he [she] attends to...." 3 These parallel and yet often competing obligations can sometimes be difficult to reconcile. This is an ongoing and obvious source of frustration and moral injury for physicians who want the best possible care for their patient. 11
Advocating on behalf of our patients, to others in the system who are seen as key players, can actually help lead to innovative solutions. Advocacy needs to be professional and not perceived as disruptive. Healthcare advocacy by physicians can occur at many levels and can take different forms. For example, doctors often advocate for individual patients by requesting timely diagnostic tests, access to certain treatments, or referral to a specialist. Physicians may advocate at the regional level or for groups of patients, for example by supporting an expanded community health center or by seeking funding for a health provider to join a hospital. At the system level, physicians may advocate for a provincial medical association/federation’s strategy for activities to improve healthcare overall.
Advocacy activities are appropriate as long as physicians act professionally, provide an informed perspective, and offer constructive input and recommendations to the appropriate groups or individuals. 2 Many Colleges have adopted policies governing physician advocacy with which physicians should be familiar.
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The large number of postponed elective medical services will add tremendous pressure to the issue of care prioritization for years to come. Physicians are expected to use their best judgment when monitoring wait lists. Healthcare providers should try to balance the best interests of their patients with the system’s capacity to deliver care, and endeavour to:
- develop effective triage systems for patients
- develop effective communication strategies between referring physicians and consultants
- work collaboratively with colleagues, institutions and health authorities to innovate and find solutions
- communicate with patients so they do not feel abandoned.
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It is prudent to document the following:
- any efforts to obtain the required resources for your individual patient (investigations, referrals etc.)
- communications with the patient or their substitute decision-maker, regarding the symptoms and signs signaling a deterioration in the patient’s condition, who should be called, where to seek care and how urgently it should be sought
- communications between referring and consulting physicians
- any efforts to advocate for appropriate resources
Because standards of care change over time, it is important to keep copies of the policies or restrictions that may have affected your decision-making.
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