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Consultations and referrals


Improving the referral-consultation process

Content of the referral request


Even in a hospital, where the medical record is generally readily available, it is important to make an explicit request for a consultation. Identifying the reason for the referral saves time and provides safer care. If the consultant is in a different location, this information becomes vital.

As a medical student you will often be directed by your supervisor to arrange a patient consultation at another hospital service (internal medicine, surgery, etc.) or with a specific physician. Consider the following cases to help you facilitate your referrals.

Case: Uninformative referral
Referral pad with phrase 'See Skin'

Background

A patient arrives at a dermatologist's office with a consultation letter. The dermatologist determines that the patient has been treated with prescription creams and ointments (names unknown) and has had blood work (type and results, unknown).

The patient is taking "tiny white pills" for the skin condition.

Examination reveals an erythematous ulcerated nodule on the patient's left calf. The patient also has a generalized macular erythema which may be an allergic reaction to the medication, an id reaction to the infection, or it may be unrelated.

Outcome

The dermatologist's office needed to contact the family physician's office to determine the blood work results and the nature of the previous prescriptions. Fortunately, this information was readily available.

Think about it

How might the poor referral note have contributed to a poor outcome for the patient?

Lessons learned

The consultant dermatologist uses the referral information to judge the urgency for the required appointment. This request had insufficient information to be able to judge when to arrange the appointment.

Without information regarding previous investigations and treatments the consulting physician must arrange to speak to the referring physician. Both physicians must interrupt their busy offices to transfer the information.

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Case: A 50-year-old male with headache
Female physician checking right pupil of middle age male patient

Background

A school teacher, with a history of headaches and hypertension, presents with severe right-sided frontal headache.

His family physician performs a thorough physical examination and notes a "sluggish right pupil" and "possible right ptosis." There are no physical findings.

The physician promptly refers the patient to a specialist with a note stating "headache - rule out pathology," but omits information about the eye findings. The specialist, concerned about the possibility of an intracranial lesion, is unable to reach the family physician by phone, however, he dictates and mails a consultation letter that same day. The patient is told to see his doctor as soon as possible.

In the following days, the patient experiences more severe headache associated with vomiting. A leaking aneurysm of the Circle of Willis is then identified. Following its clipping the patient dies due to diffuse cerebral vasospasm. A legal action begins, naming all the physicians involved.

Think about it

What might have improved the communication between the physicians?

Outcome

The judge criticized a number of care issues in this case, including the failure of the family physician and specialist to communicate effectively.

From the judgment: "Failing to include relevant clinical information in a referral amounts to negligence as a matter of law."

Lessons learned

Share what you know:
  • relevant history and physical findings
  • results of relevant investigations
  • actions taken to date
    • treatments and effects
    • other consultations and conclusions
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State your expectations:

  • What is your question? Do you want help with:
    • diagnosis?
    • management?

(Sometimes a referral is made to get a second opinion.)

  • What is the level of urgency?
  • Do you know the date of the consultation and is it appropriate given the urgency?
  • Should the consultant be contacted directly?
  • Have you considered other options if you cannot obtain a timely consultation, such as referral to another consultant or referral elsewhere?
  • Have you had a discussion with the patient to obtain consent regarding the situation and the options?
  • Have you alerted the patient to the symptoms and signs that should trigger seeking medical care while awaiting the consultation? As the referring physician, you should continue to monitor the patient pending the consultation. Request an earlier appointment as required and communicate to the consulting physician any significant changes in your patient's clinical condition.
  • Who will be the most responsible provider for follow up?
    • you
    • the consultant
    • another health professional