Why are so many patients referred to specialists?

Do generalist doctors refer to specialists too much?

Jeffrey Parks, otherwise known as the Buckeye Surgeon, has written numerous times on the issue, and his feeling is, yes, they do.

And he’s right. There are many physicians, along with mid-level providers like nurse practitioners and physician assistants, that refer to a spectrum specialists for routine conditions, especially in the hospital setting.

Dr. Parks asks, “shall we continue with the status quo of unabated mass-consults where a patient gets admitted to an internist’s service and ends up with consults from surgery, GI, ID, and renal; all for a demented little nursing home lady?”

No, we shouldn’t.

The fee-for-service payment system has something to do with the behavior, compounded with the tendency to practice defensive medicine. As long as generalist doctors continue to get sued for not consulting fast enough, the incentive will always be there to reflexively refer.

And in the outpatient setting, so long as time is not valued, some would rather send the patients off to a consultant, rather than spend the time necessary to diagnose a problem.

We know that more doctors involved in a patient’s care doesn’t necessarily improve his health. Fundamental changes in both the payment and malpractice system is the only way I know to resolve this.

Comments are moderated before they are published. Please read the comment policy.

  • pheski

    As a family physician, this bothers me when I see it in others and really angers me when I see myself doing it.

    Let’s consider the outpatient setting to make the discussion a bit more practical and grounded.

    Patient X comes in for either an annual health maintenance visit or a regular chronic disease assessment (diabetes and hypertension and lipids). While there, s/he mentions knee pain impeding exercise, some worsening of intermittent headaches, and ear pain with chewing. Because of the way health care is paid for and rationed in a fee for service setting, we already do not have adequate time to deal with issues scheduled for the visit. Each of these problems warrant their own slot of 15-20 minutes. I really have no palatable options. I can ignore the complaints: bad care, unhappy patient, but I stay close to my schedule. I can suggest that the patient return for a separate appointment to deal with these important issues so we don’t do a bad job of today’s tasks: good care if I can schedule the appointment(s) in a reasonable time frame, unhappy patient who has saved these issues up for 2 months and now has to wait for help, take more time away from work and have additional co-pays or expenses to meet a deductible, and I stay on schedule. I can do a superficial job and throw medicines or lab or xray or pseudo explanations at the patient in a hurry and not allow follow-up questions: dangerous care, happy patient until the treatments don’t work, and I am only a little further behind. I can tell the patient these are important and offer to refer: mixed good and bad care, happy patient, I stay on schedule.

    I hate it when I refer a patient for a problem I know I can competently manage – but I do it on a regular basis. Hire me to do a job and make the compensation fit the job, and I will stop. Pay me piecework, and I can’t stop.

    This happens in various forms to all primary care physicians multiple times daily.

  • Rod

    There is no incentive to “NOT REFER”, time constraints, need to see as many patients so you can bill better, lose skills that were learnt etc etc the list can go on. Every physician knows that there are excellent, good , not so good doctors in each field.
    The PCP who can handle Arrythmia, heart failure, give joint injections, lance an abscess isgreat asset than someone who will refer for each and everthing. This is what needs to be addressed, more than specialist versus genralist. How can our system reward the very best in each field and those who lack such skills should be incentivised. Some systems like Kaiser make an effort to keep their PCps current so that they refer appropriately

  • http://www.realicu.com www.realicu.com

    I practice hospital medicine and I have to acknowledge that the problem exists. Personally, I try to consult specialists only when it’s absolutely necessary. If you have too many doctors on a case it becomes a situation with too many cooks on the kitchen. Sometimes, physicians write contradictory orders (cardiology orders lasix and nephrology writes for fluids) and it becomes your problem to untangle this mess. Things can also be missed by a simple “diffusion of responsibility”. Doctors tend to overlook things as long as somebody else is supposed to manage them.
    I also agree that there is no incentive of not consulting specialists. An internist running in and out of the office to see the patients simply might not have a choice but to consult other doctors to manage the patient’s problems.

  • Paul MD

    These are very good points. We shouldn’t forget that often there are VERY good reasons to consult other specialty and subspecialty providers. We all want to get the job done and get it done right in a time and cost efficient manner.

  • http://www.cnmri.com Bob Varipapa

    We recently got ‘hospitalists’ in our local hospital. Being a neurologist, I thought we would see a decrease in consults.

    Actually, maybe in the sense of ‘unintended consequences’, hospital admissions are up as now everyone is admitted (ER likes to clear beds, either through the front door or the back door) and those admitted get multiple consults.

    Luckily, we got a neurologist-hospitalist to help with the increased work load (guess I shouldn’t complain).

  • http://curbside.posterous.com Nuclear Fire

    I often wonder why I’ve been consulted on a patient when the diagnosis and treatment seems pretty clear and is something I would have handled myself when I was a PCP. Making this situation difficult in knowing how to phrase my consult letter and what kind of follow up to provide the patient is that often there is no consult letter or clinic note sent by the consulting entity. I’m left to ponder does this doctor/NP/PA really not recognize XYZ? Do they just want a confirmation? Do they not know how to treat it? Are they worried about some comorbid factor? Did the patient demand a specialist even though you are completely capable of dealing with this and I should tell the patient how good of a job you are doing and this is clearly something his PCP should be handling? Are you too busy in your clinic, then subtly let me know so I don’t send him back for a rapid follow up; I’m happy to take care of these easy issues.

    Help me, help you. Please tell me how much help you need so I neither send the patient back without as much done as you’d like or overstep what you want and steal an easy repeat clinic visit patient from you.

    I used to think it was standard decency when consulting someone to send them a consulting letter, your last clinic note plus any others related to the issue as well as all labs/films etc. These days I get nothing on average and occasionally a few pages of normal labs with a fax cover sheet saying “reason for referral: pain.” Have SOP changed?

  • pheski

    @Nuclear Fire ~>

    Absolutely correct. Unfortunately, SOP has changed – and for the worse in this instance.

    In the setting where I saw a patient and then paused in the hall or my office to dictate the OV note, it was easy and intuitive to dictate a cover letter for a referral and list the required enclosures (lab, prior physical, etc) or cc (other providers or patient) at the bottom. It was not at all uncommon for me to do that in the room with the patient, both for accuracy and so the patient felt part of the loop. Timeliness could be impacted by my transcription system and the US Postal system, of course.

    Now I use an electronic record. I do the bulk of my documentation while interacting with the patient, who is encouraged to sit next to me so we both see my documentation unfold. This already detracts from both the time and attention I can devote to the patient. (Studies are clear that we are not capable of multitasking – we serially single task. Using a cell phone impacts our driving as if we were legally intoxicated. Using a complex eHR is undoubtedly the cause of a greater impairment than a cell phone while driving. But that is a separate rant.) An unintended consequence is that it becomes a major task to do a letter to a consultant: I have to open a separate document and type the letter and cut and paste information into it. My solution has been to include my information to the consultant in the assessment of the problem for which I am referring (“Plan: continue current pain meds, stop PT, arrange consult with neurosurgeon to see if MRI/surgery a reasonable consideration.” “Plan: patient concerned about histoy of sun exposure and requests annual skin eval by derm – will refer.”)

    Not optimal, I agree. Any thoughts about how to improve it?

  • http://curbside.tumblr.com Nuclear Fire

    I’ll also put aside my rants on EMRs except to say the problem is not the doctors, it’s poorly designed and programed software.

    I actually would find your example helpful. I rarely get that. Literally just a page or two of normal labs, if I’m lucky, and a fax cover sheet that says “pain” or “knee pain.”

    I try to train my residents and students to make sure they also explain to the patient why they are being sent to the consultant so if my letter gets lost in the mail

    I still dream that one day Google will make a wonderfully magic EMR/patient communication portal that will fix everything. I also want a pony.

Most Popular