How to refer a patient without sounding like an idiot.
Some tips for the struggling referrer.
Do you find referring patients to other centres or specialties a particularly painful process? Do you often get the impression that the person you are trying to refer to wants to stab you in the eyeball with a jelco? Do you feel like registrars at specialist centres basically live to bat patients?
You probably have horrible referral technique. No, seriously. Sometimes it’s them, but mostly it’s you and how you said it.
Here are some tips for less painful referrals. Use these often and you’ll have more receptive listeners, a higher referral success rate, and just generally better relationships with your colleagues.
Please note the tips below assume you are a good doctor with lousy referral technique. If you’re actually a lousy doctor, there’s probably not much to be done, apart from trying harder. Also, we were all lousy referrers once. But your aim is to get better with time (preferably, as little time as possible). So don’t take this too personally.
1. Introduce yourself
Basic manners, people! Do you introduce yourself to your patients? To your new boyfriend’s friends? To the banker you’re hoping to get a home loan from? Yes? So then why don’t you introduce yourself to the doctor you’re referring a patient to? They probably get called several times an hour on a busy day, by everyone from the nursing staff in their ward, to their interns, to their bosses, to insurance salespeople, to you. So give them a bit of immediate context, why don’t you? I’m not talking about a lengthy introduction including your career history and food preferences. I’m talking about a simple ‘Hi, I’m Jo, a casualty officer at Hospital X.’ Easy peasy.
(Side note: almost every single person I mentioned this post to immediately listed introduction as being of premier importance.)
2. Don’t ask the receiving doctor how they are
Look, if you actually know them, and really do care about whether or not their sore shoulder is better, whether or not their kid has finally learned to use a spoon, and whether their call is scoring a 1 or a 10 on the Call-Shit-O-Meter, then by all means, ask them how they are. But if you don’t know them, and don’t actually care about those things, why waste time on this social nicety just because your mother taught you to always ask? Just assume they are the way people on call always are: very busy, quite stressed, a little depressed, and vaguely irritable. Why go through that whole awkward exchange where you ask them how they are, they reply ‘fine’, and then there’s this weird pause? Just ditch the how-are-yous and move on.
3. Get to the point
Please, stop it with the waffling. Your referral is not a joke where the punchline needs to be delivered at the end. The person on the other end of the line isn’t listening to your story with the breathless anticipation they reserve for a good novel or movie. They just want to know what you want (an opinion, or to refer), and what the diagnosis is. You have a medical degree, and should be able to figure out a differential, even without special investigations. A simple ‘I would like to refer a patient with appendicitis/pneumonia/a stroke’ is what receiving doctors want to hear. If you can’t bring yourself to commit to a diagnosis, then at least try to group all your symptoms into a syndrome (such as acute abdomen/respiratory distress/right hemiplegia) instead of listing each of them individually and leaving the receiving doctor feeling like you’re reading a textbook out loud.
Secondly, talk at a reasonable pace. I’m not saying you need to race through your entire referral in one breath, but don’t dawdle. Seriously. Like I said earlier, on a busy day a receiving doctor will take several calls an hour. The absolute age you take to remember your own name or to advance to the next point are excruciating. Hurry it up buddy, we’ve all got things to do.
4. Hold back on the background info
Once again, the waffling. Yes, as a good doctor you should take a thorough history, but as an insightful clinician, you should know what isn’t relevant. The receiving doctor is not one of your varsity examiners you’re trying to wow with your thorough technique. They just want to know what the problem is, what potentially caused the problem, and anything that may lead to the patient’s immediate demise or deterioration if not addressed.
4.1 RVD & APGARs: A short note
Look I know there was this bad time about 10 years ago where almost all patients had HIV and almost none of them were on ARVs and really the burden of this terrible plague formed the bulk of our work and thus a patient’s status was central to any referral. But thankfully, where I work at least, those days are mostly behind us and in most cases HIV status, although important, is not relevant to the current problem and doesn’t have to be included in the précis. Smart referrers can figure out whether or not it is important in the case in front of them so that they don’t mindlessly parrot ‘Are-Vee-Dee Exposed/Unexposed/Positive but Virally Suppressed’ or whatever every time they refer a patient. Also, APGARs. Seriously guys. They mostly don’t matter by the time you’re sending the patient over for an appendisectomy. Concentrate, please.
5. Know your patient
Blood pressure, heart rate, sats, level of consciousness, temperature, and so forth. You might not get asked, but very often you will. And then there’s nothing that makes a receiving doctor want to hurl a phone against a wall more than someone who says ‘Uh, let me quickly check… Um… I’m not sure…’ when asked for these parameters. Examine your patient properly, write your findings down, and have them ready in front of you to read out. And don’t lie. Don’t oversell your patient and claim they’re in septic shock because their temperature is 37.2 and they look a bit peaky, don’t claim a patient is ‘quite well’ when they’re unconscious and drowning in their own phlegm. Tell it like it is.
6. Ditch the unnecessary descriptives
OK, this is just a personal pet hate of mine. But this is my post, so.
Terms such as ‘cute’, ‘charming’, ‘highly strung’ and ‘rude’ help one decide whether or not one is going to have someone over for tea, not whether one is going to slice them open and dig through their insides. It’s not necessary to use these words to describe your patients when you’re referring them. If you like to use terms such as ‘a charming gentleman’ to give your dull clinical notes some flare, that’s your own business, but for referral purposes, words such as ‘male’, ‘female’, ‘adult’ and ‘infant’ will do.
On that note, how about ditching cutesified nouns in medical conversation as well? Words like ‘bubba’, ‘oompie’, ‘tummy’ and ‘toofies’. There are whole dictionaries (medical and general language) full of nouns and adjectives that won’t make it sound like you work at a crêche.
7. Don’t repeatedly ask me to spell my surname
I get twitchy just thinking about this, actually. Once again: concentrate, ok? And if you didn’t get it the first time, just write some kind of approximation, or write ‘Surgeon On Call’. There is very little more painful than going “M — I — … No ‘I’ for India not ‘A’ for Apple.. L- No not ‘O’ I said ‘L’ — L! L for Lion! Are you even listening?”
8. Some receiving doctors are assholes
Yes, sometimes it’s not you, it’s them. There are people who hate accepting patients. There are people who love to bat. But if you’ve presented your patient decently and have a valid reason for referral, they can’t turn you down. If they do, and you are not satisfied with the reason they have provided, and still believe your patient needs their help (and you know this because you have taken a thorough history and examined them properly and know that there is a specific skill they need from that specific specialty), then you shouldn’t take no for an answer. If the receiving doctor is at another institution, call their senior (I find junior doctors are more prone to try bat a patient than a senior person). If that is not an option, tell them you’re going to send the patient anyway just so that they can be sure, and that you look forward to their feedback. If the patient is already at the institution where the registrar or specialist is working, invite them to pop over and make a quick note in the file regarding why they are refusing the referral/investigation/intervention. If they refuse to do that, tell them you’ll make the note on their behalf if they would just quickly spell their surname for clarity. If you are sure of yourself, have presented well, and the person you have called is being unreasonable, don’t be deterred by worries about creating enemies. The patient’s health (and, secondarily, your own personal protection from blame) are your priorities.
And sometimes, people are just grumpy assholes. They only accept your patient after lashing you with sarcasm and several minutes of derisive snorts, and leave you with the impression that they are certain you obtained your degree at an inferior institution, and anticipate your imminent hearing at the HPCSA for general incompetence. Forget them. Grow a thicker skin, and move on.
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