We did not obtain information on the number of telephone calls fielded by physicians each day. Without these data, we were unable to determine whether our methods had failed to capture some telephone referrals or to calculate telephone referral rates. In this study, family physicians made 18.9% of all referrals during telephone conversations, in contrast with pediatricians in another study4 who made 27.5% of all referrals by telephone. The difference in these proportions is not large and is probably explained by pediatricians’ greater use of the telephone for patient care.
It could be argued that the volunteer physicians in this study systematically differ from the typical family physician. The average number of visits per day among study physicians (19.7) is similar to a national estimate of 19.9 visits/day for family physicians in single specialty group practices.18 Furthermore, we found similar probabilities of referral overall and for the 10 most commonly referred conditions between study physicians and a national sample, suggesting that referral propensities between the 2 groups were similar.
Why family physicians refer
No value judgments can be made about the appropriateness of physicians’ reasons for referral. Physicians most commonly referred because they were uncertain about diagnosis or treatment and sought advice from another practitioner. For about 1 in 5 referrals, physicians recorded only a sign or symptom as the diagnosis, suggesting a reasonably high level of diagnostic uncertainty. Physicians’ tolerance of uncertainty varies markedly,19 making it difficult to judge questions about appropriateness of referrals that are made to reduce this uncertainty.
Another important reason for referral was that physicians deemed the management of the health problem to be outside their scope of practice. Physicians were more likely to refer a patient with a common problem after trying out a course of treatment than was the case for uncommon problems that were more likely to be referred for medical management.
Patients may raise the topic of possible referral. When physicians agree that referral is indicated, they almost always find other reasons for making the referral. Alternatively, physicians might make a decision to refer and justify it in part as being a result of patient request. Discussions on whether a referral is needed are common in primary care. Among referrals made in an Israeli family practice network, patients raised the topic of possible referral in 27% of cases.20 In a study of 856 internal medicine visits, 45% of patients indicated some desire to discuss the need for referral with their physician; however, physicians recognized these desires only about half the time.21
Selecting a specialist
Our results show that primary care physicians prefer to send their patients to specialists with whom they have developed a relationship. Physicians in this study maintained a high level of involvement in specialist selection, providing patients with the name of a specific practitioner for 86.2% of referrals. The most important factor in selecting a specialist in our study was the same as that found nearly 20 years ago by Ludke1: personal knowledge of the specialist. Physicians’ dissatisfaction with the specialty referral process in managed care settings22,23 could be a result of their reduced choice of specialists with whom they have forged personal relationships.
Slightly more than 1 in 6 referrals were made to specialists in the referring physician’s practice, consistent with movement of primary care physicians into multispecialty groups. Whether intrapractice referral holds any advantage over referrals outside the practice, such as better coordination and appointment adherence, awaits future study.
Our results show that physicians must not only select a specific practitioner but also choose among different types of practitioners. Some patients were sent to nonphysician clinicians and physicians (eg, podiatrists and orthopedic surgeons for acquired foot deformity), whereas others were sent to medical or surgical subspecialists (eg, nephrologists and urologists for urinary tract symptoms). These patterns are likely to reflect the need for multidisciplinary specialty care for some conditions. For instance, patients with diabetes may see an ophthalmologist for retinopathy evaluations and an endocrinologist for medical management consultation. For some conditions, there appears to be considerable uncertainty regarding the boundaries between specialists.24 Should a patient with a skin mass be sent to a general surgeon, a dermatologist, or a plastic surgeon? When should a patient with allergic rhinitis be sent to an allergist and when to an otolaryngologist? These referral patterns may reflect local care practices and specialist availability. They may also be a consequence of a surplus of specialists in this country and competition for patients.
In a survey of family physicians that was performed in the late 1980s, respondents reported that they were more likely to refer to internal medicine subspecialists than internists for adults, but preferred general pediatricians over pediatric subspecialists.25 Our findings suggest that the trend for adult patients remains, but there has been a shift away from general pediatricians toward subspecialists for pediatric referrals. These new patterns may be a consequence of greater availability of pediatric subspecialists, greater exposure of family physicians to pediatric consultants, and a larger share of family physicians who have completed residency training.