What reference do you use if unsure when to refer to specialists?

[EMgordo]

Hey all,
Some students who are rotating with me want to go into family medicine and were wondering if I knew of any reference resources that answer the question, "when is it appropriate to refer a given condition to a specialist?" Doesn't want to inappropriately refer things too early etc. I am in EM and wasn't sure the answer for outpatient patients. What resources do you all use early in training for reference on this topic?
Thanks!
Gordo

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[SLC]

Experience.

It’s a big part of what I asked specialists about as a med student. I knew I wasn’t going to be a neurologist, but wanted to learn what I could from them, including how to pass a quality referral.

 

[cj_cregg]

Sorry if this is too obvious but in addition to the above, UpToDate for most conditions I'm debating about referring for tends to have pretty hard and fast recommendations for when they need to see a specialist. AAFP articles can be a good resources as well but are usually behind a paywall for non members

 

[BigPikachu]

Therapeutic Guidelines
Family Physician Journal
Up To Date

Also lots of Hospitals and Health Services have public domain clinical guidelines and protocols that are a useful resource.

 

[dantt]

Unsure. Refer.

 

[Ironheme]

I agree with the above. Experience. Your comfort level and knowing when you should, and what you can handle plays a big part. Also, I always read what the consultant writes/does after I refer. I learn for the next time if I was on the right track, if it was appropriate, and what I could have done differently (ordered x, y, z work up prior to specialist, etc).

A good rule of thumb is asking yourself what would the specialist do that you could not. I also talk to the consultants I send patients to. They tend to give good feedback. You know you've done an appropriate referral when they come up and want to talk to you about that "interesting case" you sent over.

 

[door_to_balloon_knot]

Unsure. Refer.

That said, don’t be the dummy that literally refers for every single complaint cause you couldn’t be bothered to do an exam or check uptodate. Some FM out there literally referring away HTN management to cards and only mainly doing physicals. Great way to lose patients, easy productivity, and be known in the community for the wrong reasons.

 

[jm192]

Unsure. Refer.

I think these referrals where you're not sure can lead to a valuable learning experience.

As others have said, some of this stuff can be pretty easily learned/figured out reading UpToDate or other sources. But ultimately if you're not sure, do too much for your patient instead of risking too little.

THEN

You see what the specialist does, why they did it. Can you do that without the specialist next time?

If it's not something that always needs specialty care--A good and nice specialist will provide feedback to help guide you in the future.

Learn from these.

 

[EMgordo]

Thank you everyone, this was super helpful!

 

[Sushirolls]

I'm Psych. Recently moved to middle of nowhere.
Slowly the PCPs are circulating my cell phone number that Sushi will curbside.
I start off be declaring that my name better be entered into any chart, and secondly, I'm not talking about real patients but only hypothetical.

The PCP gets what they want. A starting point, or more confidence to continue whatever plan, or more willingness to refer.

IM/FM shouldn't forget that usual insurance based practices are 2000-4000 or more patients. They have the ability to refer to who and where they want and most patients will listen to their PCP. Specialists, depending on their field, are likely to be dependent on PCPs and those referral patterns mean something.

You don't have to refer within your Big Box shop. You don't have to refer to the person who is closest simply because they are closest. "Patient, close doc specialist isn't the best but if you can't travel I get it, they'll be good enough, but if you can travel I have a better working relationship with dr almost nearby, and they provide better communication."

I have a DPC practice in my rural place, that I have not seen a single referral from, and probably there are patients that should come my way but aren't. I have some PCPs in one of the Big Box shop groups who talking with me is now sending every single psych patient the person has on their panel. Others in the group continue to manage themselves.

Then you have some specialists who throw up road blocks. Insurance wise, they don't need referrals, but their office requires it. Or recently I saw from a neurology office, basically said no one crosses their threshold until most every record is sent, and their entire multi million work up is already ordered AND completed - in advance.

So the poster above who said experience, is absolutely right.
And the post who said refer when in doubt, is right, too.

Lot of gray.

 

[Keona]

We rotated with a lot of specialists and one of the big goals of the rotations was to make sure we knew what needed referred and what we could handle ourselves

 

[VenusinFurs]

First question: is there even a specialist to refer to who the patient can get to and afford.

 

[FrustratedFamDoc]

Our local independent practices routinely no charges the self pay patients I send their way. It’s the right thing to do, and they appreciate the volume of well insured patients I send their way.