After completion of this module, the participant will:
1) Understand the risks associated with poor communication in the consult and referral process.
2) Identify the key elements of optimal consult or referral request letters.
3) Identify strategies which may improve the quality and completeness of consult and referral request letters.
The Consultation and Referral Process
A consultation involves another health professional (most often a specialist physician) performing a specific diagnostic or therapeutic task without transfer of responsibility for the patient’s care or ongoing management of a specific problem. A referral involves sending a patient for the ongoing management of a specific problem with the expectation that the patient will continue to see the original physician for the overall coordination of care (Nutting et al, 1992).
The components of the consultation or referral can be summarized as follows:
1) the family physician and the patient recognize the need for consultation and referral;
2) the family physician communicates the reason for the consultation and referral along with relevant clinical information to the specialist;
3) the specialist evaluates the patient’s condition;
4) the specialist communicates the findings and recommendations to the family physician, an;
5) the patient, the family physician and the specialist understand their responsibilities for continuing care.
Problems in the process can occur at any step and most are attributable to failures in communication and discordant expectations.
Think: What kinds of problems can occur due to poor communication?
Poor communication in the consultation and referral process can lead to:
1) poor continuity of care,
2) delayed diagnoses,
4) unnecessary testing and
5) repetition of investigations.
All of these can reduce quality of care while increasing health care costs and litigation risk (Epstein, 1995; Gandhi and al, 2000). Studies have shown that both primary care physicians and specialists are often dissatisfied with the quality and content of written communication. Specialists have most often expressed concerns regarding the frequent absence of an explanation for the referral, as well as lack of clinical findings, test results and details of previous treatments (Newton et al, 1992; Newton et al, 1994; Tattersall et al, 2002). On the other end, referring physicians report receiving feedback from consultants in only 55% of cases (Bourget et al, 1980). When they do receive feedback, it may lack essential information needed for the patient’s ongoing management (Dojeiji et al, 1997; Scott et al, 2004).
What makes a good letter?
Activity: Imagine for a moment that you are a consultant gastroenterologist and you receive the following consultation request letter:
How would you feel after reading this letter?
What would be your impression of the referring physician?
What information would you like to have seen included in the letter?
How should the information be presented?
Dr. A. Smith
River City Medical Centre
222 River Road, River City
Re: Williams, Pat
DOB: 19 June 1956
123 5th Avenue, Springfield
Please see Pat for assessment. Pat is a pleasant 51 year-old with a family history of colon cancer and has recently h ad an episode of rectal bleeding.
Factors that affect the overall quality of letters can be divided into two broad categories: content and style.
It is important to recognize that the content of letters needs to meet the needs of the target audience – the specialist, in this case. Different specialities and different patient problems will require the supply of differing amounts and types of information. Audits of
consultation/referral request letters and surveys of recipient specialists highlight the necessary or ‘core’ content of letters (Gandhi et al 2000; Hansen et al 1982; Newton et al 1992; Jenkins RM 1993):
1) Demographic data: All letters should include relevant patient demographics: patient’s name, sex, date of birth, full address, telephone number and health number.
2) Initial statement outlining reason for referral: A single sentence introduction including gender, age, and problem/reason for consultation helps the reader in more efficiently processing subsequent information.
3) History of the presenting problem: This should include a description of the chief complaint, associated symptoms and relevant collateral history.
4) Past history: Audits of consultation/referral request letters show that past history is outlined only 30-60% of the time. Letters should include summaries of medical, surgical, and, if relevant, of obstetrical histories.
5) Psychosocial history: Letters should include relevant family, work and travel histories as well as habits depending on the presenting problem.
6) Medications: Although 92% of consultants surveyed expect letters to include a list of current medications, it is often absent (44% of the time) or incomplete (over 30% of the time). All letters should include an up-to-date medication list which includes over-the-counter and herbal products.
7) Allergies: All letters should list the presence (or absence) of allergies and intolerances.
8) Physical findings: A description of relevant clinical findings should be included in letters.
9) Investigations: Family physicians include test results less than half of the time (45%), leading to unnecessary repetition of tests by the consultant. List all laboratory/imaging investigations done and indicate if any others have been initiated even though results are not yet available. Copies of original reports should be attached.
10) Outline management to date: Previous treatment or therapeutic interventions are indicated in only half of all letters. Outlining management that has occurred to date and the response to therapy may assist the consultant in selecting more effective treatment options.
11) Clinical impression: Family physicians often hesitate to provide provisional diagnoses (provided in only 66% of letters). The development of a clinical impression provides the rationale for your clinical request.
12) Outline expectation(s): The reason for the consultation and the referring physician’s expectation(s) should be clearly stated in the letter. One study at large teaching hospital found that the referring physician and the consultant completely disagreed on both the reason for the consultation and the principle issue in 14% of consultations (Lee et al 1983). Specific expectations regarding return of the patient or the urgency of the consultation should also be clearly stated.
Although it has been shown that the quality of consultants’ reports increases directly with the amount of referral information originally received, one must not overlook the impact of style on the overall usability of a letter (Hansen J et al, 1982). Planning the letter before dictating will result in it being more succinct and organized. Too often the letter provides excessive information, the tone is too conversational, it lacks structure and is too verbose (Manning, 1989).
Writing experts recommend that authors limit the length of paragraphs to fewer than five sentences and limit the number of words that have more than three syllables. Limiting one idea per sentence and one topic per paragraph will also make letters easier and faster to read. Structuring letters with the use of headings and lists can also make information easier to retrieve. It should be noted that use of electronic medical records can facilitate the formulation of consultation/referral request letters by automatically extracting relevant data from the chart. If the author of the letter presented in the previous activity had redrafted his or her letter using the suggested content and style elements (see below), it would have been significantly more useful to the recipient consultant.
Dr. A. Smith
River City Medical Centre
222 River Road, River City
RE: Williams, Pat
123 5th Avenue, Springfield
Tel: 555-222-0002 (home)
I’d appreciate your assessment with view of colonoscopy for this 51 year-old gentleman who is at increased risk of colon cancer.
One month ago, he reported having had a single episode of rectal bleeding consisting of a small amount of bright red blood after having passed stool. He reported having some rectal pain associated with the episode. He has not had any further recurrence of rectal bleeding and at present has no other gastrointestinal symptoms – specifically he reports no alterations in bowel movements, no dyspepsia nor any weight loss.
On review of his family history he reports that both his father and a paternal uncle have had colon cancer.
Past Medical History: Nil
Past Surgical History: Tonsillectomy 1965; appendectomy 1976
Medications: Select multivitamin 1 tab PO once daily
Family History: Father died of metastatic colon cancer at age 64. Mother alive and well, age 76. 2 brothers alive and well, ages 45 and 48. Paternal uncle with colon cancer at age 62, treated with partial colectomy.
Mr. William’s physical exam is unremarkable. His height is 1.76 m and his weight is
76.7 kg. On abdominal exam there are no palpable masses and there is no organomegaly. Rectal exam is normal.
I think Mr. William’s single episode of rectal bleeding was likely the result of an anal fissure which has now healed but in light of his family history of colon cancer, I’d appreciate your assessment with view of performing a screening colonoscopy.
Dr. A. Smith
Activity: Use the following letter assessment tool after dictating your next consultation or referral request letter. Once the assessment is complete, redraft the letter to improve its quality and completeness.
Consult and Referral Request Letter Assessment Tool
Date of letter: __________________________
Discipline letter directed to: _______________
1) Patient demographics: YES NO
2) Initial statement identifying the reason for the referral: YES NO
3) Description of chief complaint: YES NO
4) Description of associated symptoms: YES NO
5) Description of relevant collateral history: YES NO
6) Past medical history: YES NO
7) Past surgical history: YES NO
8) Relevant psycho-social history: YES NO
9) Current medication list: YES NO
10) Allergies: YES NO
11) Relevant clinical findings: YES NO
12) Results of investigations to date: YES NO
13) Outline of management to date: YES NO
14) Provisional diagnosis/clinical impression: YES NO
15) Statement of what is expected from the referral: YES NO
16) One topic per paragraph: YES NO
17) Paragraphs with fewer than 5 sentences: YES NO
18) One idea per sentence: YES NO
References and Reading List
Bourguet, C., Gilchrist, V. & McCord, G. 1998, ‘The consultation and referral process: a report from NEON (Northeastern Ohio Network)’ Journal of Family Practice, vol. 46, pp. 47-53.
Dojeiji, S., Marks, M. & Keely, E. 1997, ‘Referral and consultation letters: enhancing communication between family physicians and specialists’ Clinical Investigative Medicine, vol. 20, suppl. 4, pp. S49.
Epstein, R.M. 1995, ‘Communication between primary care physicians and consultants’ Archives of Family Medicine, vol. 4, pp. 403-409.
Gandhi, T., Sittig, D.F., Franklin, B.S., Sussman, A.J., Fairchild, D.G. & Bates, D.W. 2000, ‘Communication breakdown in the outpatient referral process’ Journal of General Internal Medicine, vol. 15, pp. 626-631.
Jenkins, R.M. 1993, ‘Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner’ British Journal of General Practice, vol. 43, pp. 111-113.
Lee T., Pappius E.M., Goldman, L. 1983, ‘Impact of inter-physician communication on the effectiveness of medical consultations’ American Journal of Medicine, vol. 74, pp. 106-112.
Lingard, L., Hodges, B., Macrae, H. & Freeman, R. 2004, ‘Expert and trainee determinations of rhetorical relevance in referral and consultation letters’ Medical Education, vol. 38, pp.168-176.
Nestel, D. & Kidd, J. 2004, ‘Teaching and learning about written communications in a United Kingdom medical school’ Education for Health, vol. 17, no. 1, pp. 27-34.
Newton, J., Eccles, M. & Hutchison, A. 1992, ‘Communications between general practitioners and consultants. What should there letters contain?’ British Medical Journal, vol. 304, pp. 821-824.
Newton, J., Hutchinson, A., Hayes, V. 1994, ‘Do clinicians tell each other enough? An analysis of referral communication in two specialties’. Family Practice, vol. 1, pp.15-20.
Nutting, P., Franks, P., Clancy C. 1992, ‘Referral and consultation in primary care: Do we understand what we are doing?’ Journal of Family Practice, vol. 35, no. 1, pp. 21-23.
Royal College of Physicians and Surgeons of Canada & College of Family Physicians of Canada. 1993, The relationship between family physicians and specialist/consultants in the provision of patient care. The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada Joint task force report.
Royal College of Physicians and Surgeons of Canada & College of Family Physicians of Canada 2006, Family physicians and other specialists: Working and learning together (conjoint discussion paper). The Royal College of Physicians and Surgeons of Canada and the College of Family Physicians of Canada Joint task force report.
Scott, I.A., Mitchell, C.A. & Logan, E. 2004, ‘Audit of a consultant’s physicians’ reply for referrals to clinics in a tertiary teaching hospital’ Internal Medicine Journal, vol. 34, pp.31-7.
Tattersall, M.H.N., Griffin, A., Dunn, S.M., Scatchard, K. & Butow, P.N. 1995, ‘Writing to referring doctors after a new patient consultation: What is wanted and what was contained in letters from one medical oncologist?’ Australian & New Zealand Journal of Medicine, vol. 25, pp. 479-482.
Tattersall, M.H.N., Butow, P.N., Brown, J.E. & Thompson, J.F. 2002, ‘Improving doctors’ letters’ Medical Journal of Australia, vol. 177, no. 4, pp.516-520.
For more information, please contact:
José Francois MD MMedEd CCFP FCFP
Head, Department of Family Medicine
College of Medicine | Faculty of Health Sciences
Medical Director, Family Medicine Program
Winnipeg Regional Health Authority
P219-770 Bannatyne Ave | Winnipeg | Manitoba | R3E 0W3
Phone: 204-981-4109 Fax: 204-789-3911
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