How do we refer patients? Why do we? When do we make a referral?

I was taught at length in medical school aspects of communicating with both professionals and patients but I was never taught how to refer a patient to another healthcare professional. This particular skill has taken time, practice and reflecting upon both good and bad experiences in order to hone.

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who

The first thing to consider when referring a patient is who do you need to call? This may differ depending on the situation you are in. As a general principle, if you are calling for specialist advice/opinion regarding a patient, you need to contact someone able to provide that opinion: a registrar or above. If you are calling from the ED for a patient to be admitted then usually it would be an SHO you would be calling. It is worth considering that the person you are calling is right before picking up the phone.

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Once you have worked out who to contact, run over your referral once in your mind to ensure you know what you’re going to be saying. Clarity from the word go is key to a good referral. If you know already that you will need extra information then have it accessible. That may mean having the patient notes open to a page or the electronic records open on screen in front of you. This way, the information you need can be found readily and does not rely on your working memory for recall, allowing you to concentrate on communicating effectively.

how

How do we actually make a referral? The first part of the referral isn’t the patient’s details, it’s how you greet the person you are speaking to. I have always found friendly and professional works better than regimental cold factual communication. Answer the phone by saying where you are, that way the person you bleeped knows already where you and the patient are without having to ask. Allow them to say who they are and if they don’t volunteer the information immediately, check they are the person you think they should be. Use your first name and then ask them their name by saying “I’m sorry, I didn’t catch your name.” The other person will give you theirs and you’ve already established the beginning of rapport. Your rank or status is irrelevant in this process. Don’t allow a power dynamic to exist in the conversation and just refer to yourself as one of the doctors (medical doctor, surgical doctor, paediatric doctor etc). You should be expecting to be treated the same regardless of your status.

Be clear about your reason for calling. If you have a referral, say so. If you are calling for advice, say you want their advice. The two are different conversations. The last thing you want is someone giving you verbal advice when you wanted to refer a patient instead. Leave no doubt about your reason for calling and the conversation will be smoother. Rarely, you may be faced with someone telling you they’ll be the judge of whether or not they see the patient. In this situation, accept that they are merely trying to intimidate you, ignore the comment and just continue.

How you structure your referral is up to you. The most commonly taught and probably used method in the NHS is by SBAR (1). That is:

  • Situation – The present situation and your reason for calling. “Hello, I’m Gareth, one of the medical doctors on the ward and I have a referral for you. It is a 63 year old chap with suspected bowel obstruction admitted originally as gastroenteritis but AXR shows dilated loops of small bowel.”
  • Background – Stick to the background relevant to the situation. I sometimes hear lengthy descriptions of past medical histories or detailed histories of presenting complaints. “He was admitted with 2 days of vomiting and watery stool 2 days ago but has continued to vomit and today isn’t passing wind. He has diabetes, ischaemic heart disease and previously had a cholecystectomy.”
  • Assessment – Your actual assessment of the patient. It may include your examination findings, the patient’s observations or blood results. Again, keep it short and to the point. Not every result needs reading out and if the other person needs more results, they can ask you or look for themselves. “On assessment, he has a distended, tense, tympanic abdomen. His observations are within normal limits. He does have an AKI with a creatinine of 121 and urea 10.1, WCC is raised at 15.2 and CRP 168.”
  • Response/Recommendation – What you think needs to happen next. We have already stated we have a referral but it is worth emphasising you would like them to review the patient or state the particular thing you want advice on. If you have ordered an investigation they will want the result of then tell them you have. “I would appreciate you reviewing this patient with a bowel obstruction. I have ordered an urgent CT abdomen. Will you be seeing them before or after the CT?”

Your final sentence of your recommendation can get your answer about if they will see the patient without asking the direct question. The supposition is that they will see the patient. We allow them to make the choice as to when they do, opposed to choosing whether or not they see the patient. You do not need to employ this tactic every time, but for some more difficult people it can get the right result with much more ease. However, if you need someone to come immediately, then say so. The urgency of the review is decided by the referrer in the first instance. It is then down to those taking referrals to decide where that fits with their existing workload.

There are other structures describe in the literature (1). The commonality between any structured communication is that they are used as a means of standardising how we communicate. By doing so, we ensure our messages are delivered effectively each time. You will find the more you use a particular format, the more natural it will feel. Your own style will come through so don’t worry about rigidly applying one structure if it doesn’t work for you.

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Troubleshooting

Rarely, you will encounter rudeness when making referrals. This is a difficult situation. The best way to deal with it is to remain professional. The person being rude may be having the worst imaginable day but there is no way we could know that and it certianly is not a personal thing. If you face someone who is obviously doing so in order to intmidate you, rise above it. The best thing you can do is take a breath, focus and keep going. You have seen the patient, you know the situation, you know your referral is the right thing to do.

What do you do if you either don’t understand the reason for the referral or even diasgree with the referral? We are allowed to ask questions. It could be that there is an aspect of the case that you or your senior had not fully appreciated and a brief conversation can clear up these discrepencies. It never comes across well if you start your referral with “My consultant asked me to call you….” because the impression you potentially give is: a) your consultant didn’t want to talk themselves b) you don’t know why you’re doing it anyway c) you are just a junior and can be hassled into backing down. Clarify your senior’s position before picking up the phone and the conversation is much easier.

What if they say no? Ask them why. There may be information you had omitted which would alter their opinion. Especially if you are in the ED, ask who they believe is more appropriate and agree to call them. However, ensure you say that if the other specialty disagrees, you will be calling them back. The other option is to speak to a senior in order to clarify your reasononing and strengthen your case. In rare circumstances, you may need to ask your senior to take over the referral if the other person has been very difficult. However you handle it, remember we’re talking about patients who are people not tennis balls in a rally.

Avoid accepting advice from those not qualified to give it. Yes, I know inpatient specialties would prefer a lighter workload but most of the time, SHO level doctors would not be sufficient to provide advice rather than see a patient. There are some circumstances where it is different, for example when there is no on site registrar grade, but you should remain assertive that you were asking them to review the patient whilst thanking them for their advice. You can appeal to their ego subtly by telling them you appreciate their advice but you believe they would be able to offer even more help to the patient in person.

when

In the podcast, I mention seeing the patients journey as a graph, a curve from point 0 (time zero with no interventions) to the point of maximum interventions in the shortest time possible. When does the referral happen? At it’s simplest: any point along the way that you realise you need another person to come and do something you cannot. Especially if we are talking about an unwell patient, we want that curve to be steep going up towards a plateau of stability.

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As much as possible, we should be referring as soon as we know it is needed. I will often refer a patient from the ED based on my clinical impression of the patient. For some patients, it is obvious they need referring on, for other patients it is less so. If it is obvious a patient needs referring then just refer and explain as part of your recommendation that certain investigations have been organised but results are awaited. There are few situations where an investigation must be done prior to referral but that is often because it is the investigation that decides the referral, for example an ECG showing STEMI to cardiology, a CT head with SAH to neurosurgery.

Ultimately, it is only through making referrals you can develop a style that works for you. When you next make a referral, pay some attention to how the other person reacts to you. If it goes smoothly, what enabled that? If you get asked lots of questions, are you missing vital pieces of information? If it goes badly, try contrast it with one that went well and see if you can find the differences.

If you listen to the “Mind of the Resuscitationist” series of podcasts from EmCrit by Scott Weingart or look up Cliff Reid online and his RESUS.ME! site, you can find a lot of information about simply making things happen. Though these are focussed towards critical care and resuscitation, there are general principles that can be applied to many situations. Check out St Emlyns for another discussion on referrals.

I would be really interested to hear from you about aspects of referrals that you have found helpful in order to disseminate this advice to a wider audience.

 

Speak soon!

Gareth

References

  1. J Dunsford Structured Communication: Improving Patient Safety with SBAR. Nursing for Women’s Health 2009;13(5):384-390
  2. L Riesenberg, Systematic Review of Handoff Mnemonics Literature. Am J Med Qual 2009;24(3):196 – 204  

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