A protocol for mutual respect and communication.

When Robert Fulghum wrote All I Really Need to Know I Learned in Kindergarten, I wouldn't have believed that it would become the quintessential text for the management of a medical staff and the interrelationships required to oversee patient care. Physicians relating to each other, discussing a patient's problems, needs, and care plans, should be the easiest part of medical practice. Unfortunately, exchanging meaningful information between physicians and their offices is, at times, formidable.

As the arbitrator between physician offices, I decided that the interest of patient care (and the preservation of my sanity) would be best served by developing a protocol for the "right way" to manage patient referrals. Initially, the physicians had to arrive at a mutual understanding about each other's needs and become sensitive to the changing and diverse needs of patients in a variety of physician-patient relationships.

For example, the reason and timing of patient referrals in some rural areas with small hospitals and minimal technological resources often differs from those by physicians who may be practicing in the same tertiary care center as the specialists. The specialists, who may have never visited a 60-bed rural hospital, often have no concept regarding delivery of care in that setting. The primary caregiver at a remote site may be forced to refer a time-consuming diagnostic problem to another level of care before making a definitive diagnosis. This may frustrate the subspecialist, who may not feel responsible for a "primary" workup.

Our solution was to obtain a consensus of the guiding principles for our referral practices, develop an understanding of the requirements of each side, and then agree on a protocol. By inviting the primary caregivers to sit "at the table" with a wide variety of specialists, we were able to develop working guidelines that define five types of referrals.

1. Urgent referral is for the patient in the hospital, emergency department or physician's office, who must be transferred and seen immediately. Managed by the referring physician, the specialist is contacted directly and given the basic information regarding the patient's condition and status, as well as the means of transport and expected arrival time. Communicating this information is essential to identifying any problems or delays that may be encountered at the tertiary hospital or specialty area and that can be relayed to the patient and family before their arrival. Appropriate written records must be dispatched with the patient. Upon discharge from the hospital, the specialist will release the patient to the referring physician, providing a written summary of the hospital stay, including follow-up recommendations.

2. Traditional or consultative referral is for the outpatient seen in the physician's office and who is referred to a specialist for further diagnostic evaluation and recommendations for treatment. Traditional referrals are physician-to-physician. Each specialist establishes guidelines, including patient information, and the diagnostic procedures preferred for each of the most common referrals. If possible, the diagnostic work is performed using the referring physician's or the local hospital's resources. The referring physician coordinates transfer of requested information with the patient's scheduled office visit.

The consultant should see the patient at the earliest opportunity, not to exceed three weeks, unless both the referring physician and the patient concur. If the patient's condition is serious, the consultant immediately phones the referring physician. A letter or fax is appropriate for nonurgent cases. The consultant will discuss the findings with the referring physician and follow his/her counsel regarding any additional specialty consultation or subsequent referrals. Being sensitive to the resources available at the referring site is important.

The consultant provides a written report including diagnostic findings, treatment, and additional recommendations within 72 hours of the appointment and/or receipt of all the pertinent data. (The patient needs to understand that a delay may occur until all the studies are returned for evaluation).

The patient will be returned for treatment by the referring physician at the earliest time practical within the care plan. The highest level of professional courtesy and respect is to be exercised by physicians when discussing diagnosis and treatment with colleagues, patients, families, and other professionals. At no time is it appropriate to make negative comments about other physicians.

3. The second opinion referral, whether patient or payer requested, is a referral to an appropriate specialist for another opinion. The physician completing the second opinion will not accept the patient for ongoing care. All appropriate diagnostic work will be performed by the referring physician, whenever possible. A written report will be shared with the referring physician.

4. An informal or curbstone consultation is a situation in which the patient is not usually seen by the consultant. The attending physician seeks advice on therapy, diagnostic workup, or approaches to care. By its nature, this consultation is informal. It should be appropriate and infrequent, with a traditional consult for the more complicated problems.

5. Referral for care and treatment occurs when the primary care physician determines that a patient requires specialty care that he or she does not provide. The primary care physician refers the patient to the specialist, who treats and discharges the patient and informs the referring physician of the disposition. This protocol is a further level of communication and understanding on the traditional referral category.

The importance of good communication and respect cannot be overstated. When the specialist receives a patient for evaluation, he/she should be provided with a summary of the primary concern, a brief history and physical, a summary of the patient's past medical history including hospital admissions, current medications and treatments, allergy history, and any pertinent laboratory and radiology reports. If this is a patient who has recently been hospitalized, a complete hospital record is also useful.

The referring physician needs a quick response with a summary of the findings and recommendations for treatment and/or follow-up. A `thank you' for the referral also is recommended.

The implementation of this protocol for referral has clarified the rules for playing in the Sunday School sandbox, a la Mr. Fulghum, and has promoted meaningful and productive professional relationships in the community.

David W. Doupe, MD, FACPE, is former Senior Vice President for Medical Affairs at Hamot Medical Center in Erie, Pennsylvania, where he helped develop the guiding principles for physician referral protocols. Now enrolled in the Graduate School of Public Health at the University of Pittsburgh, Dr. Doupe will continue to work with Hamot in pursuing the Healthy Communities concept for Erie. He can be reached at 814/455-8267.