Family physicians' referral decisions: results from the ASPN referral study - Original Research

Journal of Family Practice, March, 2002 by Christopher B. Forrest, Paul A. Nutting, Barbara Starfield, Sarah Von Schrader

In a survey of family physicians that was performed in the late 1980s, respondents reported that they were more likely to refer to internal medicine subspecialists than internists for adults, but preferred general pediatricians over pediatric subspecialists. (25) Our findings suggest that the trend for adult patients remains, but there has been a shift away from general pediatricians toward subspecialists for pediatric referrals. These new patterns may be a consequence of any of several factors, such as greater availability of pediatric subspecialists, greater exposure of family physicians to pediatric consultants, and a larger share of family physicians who have completed residency training.

Implications for Physician Training

Fifty conditions accounted for 76% of all specialty referrals made during office visits in this study. Interactions with most types of specialists are generally limited to a few conditions; 3 health problems accounted for more than half of referrals to most specialties. Educators should ensure that these commonly referred conditions are emphasized in curricula that provide family physicians with the skills necessary to expand their scope of practice, when appropriate; determine when a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

Physicians in training should be taught the skills required to recognize the boundaries of their clinical uncertainty and scopes of practice. A challenge for educators is to assist trainees in determining when to tolerate clinical uncertainty while employing a watchful waiting approach and when to initiate a more aggressive evaluation, including when to obtain specialty referral. Modes of implementing these approaches are likely to differ across conditions. Thus, it makes sense in physician training to place the greatest emphasis on conditions for which family physicians commonly refer.

Under certain circumstances, patient request for a specialty consultation may be a sufficient and legitimate reason for referral. For example, as we found in this study, patients with uncommon health problems may seek reassurance from specialists skilled in the management of their specific condition. Managing access to specialists, particularly when the physician is acting as an administrative gatekeeper to referrals, can be challenging. (21) When doctors and patients disagree on the need for referral, patients may become dissatisfied with their health care (26) and decide to self-refer to specialty care. (17) In consideration of the increasing complexity of medical care, developing skills that help physicians discuss and negotiate access to specialized services with both patients and specialists has never been more timely.