One of the joys of being a family doctor is seeing a patient and knowing I’ll be able to help them fairly quickly, right off the bat. My patients appreciate that. Sometimes they need specialty care, which is an important part of treatment, but I was never taught when to send someone to a dermatologist or radiologist or surgeon. Specialty referral is not part of medical training. Doctors pick up notions of when to refer, not from textbooks but from seeing what our peers and teachers do.
That’s why primary care physicians vary by five- to ten-fold or higher in our specialty referral rates. We’re all trying to give our patients the best care, but we don’t always know when that means continuing to care for them on our own or sending them to a specialist. Overly high referral rates affect everyone. It means that busy specialists see patients who don’t need their level of expertise, which is not a good use of their skills and time. Health care systems, and patients, pay for over-referral in dollars and time because resources are not being used effectively. Patients waste time and money and risk side effects from care they may not need. They might even delay getting care from a primary care physician with whom they have a trusting relationship.
Until now, no one has examined if we can change the way we as primary care physicians refer to specialty care. We talk all the time about what drugs to prescribe or tests to order, but we don’t teach or talk explicitly about referrals, even though it’s just as important as other components of care. I’m part of a pilot project funded by the Group Health Foundation Partnership for Innovation that wants to change that. Our project gives primary care physicians a chance to discuss and strategize about effective specialty referral and alternative approaches to provide the best care for our patients.
Just this year, we’ve started with specialty-referral coaching sessions at two Group Health primary care clinics. So far, we have four primary care physicians who are coaching four other primary care physicians. In fact, we are all learning through our open discussions. I appreciate and admire the physicians who are participating in our pilot program and working with us to improve it. They are truly committed to giving our patients the highest quality of care that is meaningful to them—including getting them to the right specialist at the right time. Together, we are rethinking what primary care physicians should consider when determining whether and when to refer a patient to specialty care.
Our discussions have influenced my own practice. When I’m thinking about referring a patient to a specialist, I now ask myself three things: Is referral going to add value to the patient’s care? What is the right timing for referral—now or after we’ve tried different approaches? And if we need to bring in a specialist, does the patient need a face-to-face visit, or can we do a virtual consultation by sending a history, their story or lab tests or photos, and getting an opinion that way?
I get immense professional satisfaction from talking with other doctors about an issue that is important to us, our delivery system, and our patients. Thinking about when and how to refer to specialty care has already become part of my examined life as a doctor. It’s also part of multi-specialty medical practice at Group Health. Our orthopedic surgeons now have a short questionnaire for primary care doctors who are referring patients. It checks that both the doctor and the patient agree that surgery will likely benefit the patient. The exact wording is: “Do you and the patient feel that elective surgery is indicated now for this orthopedic problem? (Yes, No)”
Our specialty referral project could eventually have national impact. As a country, we’ve recently started talking about the idea of stewardship of our resources. I’m not talking about limiting care for patients or punishing physicians for unnecessary prescriptions, tests or referrals, but using our health care resources wisely to good end. As health care changes, especially with accountable care organizations forming to keep people healthy and control costs, reducing unneeded specialty referral will be part of the discussion. It’s an issue that is not going away.
For now, the eight family physicians in our pilot project are learning how to coach each other about specialty referral. Our focus is on how we can improve the quality of our care today. Our patients know that we’ll look after them. They trust us to refer them to a specialist when they need one but not to waste their time or money by sending them for appointments, tests, or surgeries that probably won’t help them. This project is about taking that trust seriously.
Travis A. Abbott, MD, is a physician at the Group Health Family Health Center in Seattle. He has been practicing family medicine for more than 40 years.
Dr. Abbott leads the Optimizing Specialty Referrals: a Physician Coaching Pilot Project funded by the Group Health Foundation Partnership for Innovation, with three other Group Health physicians: Sarah Levy, MD; Matt Handley, MD; and Robert Reid, MD, PhD, who is also a senior investigator at Group Health Research Institute (GHRI). Other members of the team at GHRI include: Ed Wagner, MD, MPH; Evette Ludman, PhD; Eva Chang, PhD; Leah Tuzzio, MPH; and Doug Kane.
New York Times, March 17, 2015