How do you decide to refer a patient?

[carn311]

Do you often refer patients to specialists for treatment or for diagnosis? How often do you find that you are unable to diagnose a patient?

Would anyone be willing to provide an anecdotal patient encounter that resulted in a referral? I am mostly just interested in how one comes to the decision to refer a patient.

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[sophiejane]

Just my impression, but I've rarely seen a referral done because a physician was unable to diagnose. It's not a matter of inability to diagnose, but rather one of scope of practice.

Real case: 58 year old merchant marine with weight loss >40 lbs in 8 months, dysphagia for solids and some liquids, smoker. Family doc strongly suspects esophageal cancer ( AFTER 4th year medical student presents the case and gives her impression, which he agrees with ) but can't diagnose without endoscopy, which he doesn't do in his practice. Refers to GI for endoscopy, and diagnosis of esophageal cancer is made. GI gets the glory, FPs do all the thinking.

In my experience, referrals have been done more for procedures or simply at the patients' request, than anything.

To think of referral as a sort of failure is missing the point of the team approach to healthcare.

ps: the patient actually presented with a CC not of weight loss and dysphagia, but because of a lump in the center of his chest. The "lump" was actually his xyphoid process, which was now protruding due to his weight loss. Aforementioned medical student also picked this up, thank you very much.

 

[McDoctor]

Many times it is for procedures or more detailed exam than possible in our clinic. I refer patients with tobacco history and chronic cough to ENT for a good nasopharyngeal and laryngeal exam.

Sometimes, I refer to specialists when I don't know the diagnosis. Often this is the case with vague, but persistent, musculoskeletal complaints and joint pains. I refer to rheumatology, and often the diagnosis is fibromyalgia. I prefer not to make that call.

I refer to GI alot. For endoscopies, mostly, and because I tend to see alot of patients with Hepatitis C.

I refer to nephrology when GFR is less than 60. There is evidence that patients have better outcomes in this instance.

I refer diabetics to ophthalmology and podiatry.

Anyone with cancer goes to Hem/Onc.

I refer all patients who drive me crazy to psychiatry.

But mostly, you go to a specialist when you have a clinical question which exceeds your depth of knowledge on a subject.

I had a morbidly obese clinic patient with fatty infiltration of the liver on ultrasound. She had slightly elevated AST and ALT in the past and currently. She had elevated globulins and her albumin is slightly low. An ESR was ordered at some point and was in the 70's. This persists for several months. She has glucose intolerance and hypertension. Hepatitis studies, Fe studies, autoimmune hepatitis panel, all negative.

I sent her to GI because I want to know if this picture is consistent with NASH, as I suspect, and could that cause an elevated ESR to the 70's, or do I need to go fishing to explain her apparent chronic inflammation. I want to know if a liver biopsy is indicated, given her decline in albumin. Perhaps the results would influence a decision on bariatric surgery. I want to know if the studies I ordered effectively rule out autoimmune hepatitis, or should further testing be done.

Also, sometimes in the context of our residency clinic, I refer people with chronic conditions to a specialist just for the sake of giving them continuity in care. That way, though they see a different primary care doctor every two years, at least they have the same endocrinologist for their type I diabetes, for example.

Hope this helped.