Reasons for outpatient referrals from generalists to specialists

OBJECTIVE: To determine the relative importance of medical and nonmedical f actors influencing generalists' decisions to refer, and of the factors that might avert unnecessary referrals. DESIGN: Prospective survey of all referrals from generalists to subspeciali sts over a B-month period. SETTING: University hospital outpatient clinics. PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, fa mily medicine, dermatology, orthopedics, gastroenterology, and rheumatology . MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a nu mber of medical and nonmedical reasons for referral, as well as factors tha t may have helped avert the referral; the specialist seeing the patient the n rated the appropriateness, timeliness, and complexity of the referral. Bo th physicians rated the potential avoidability of the referral by telephone consultation. Generalists were influenced by a combination of both medical and nonmedical reasons for 76% of the referrals, by only medical reasons i n 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, gener alists felt that training In simple procedures or communication with a gene ralist or specialist colleague would have allowed them to avoid referral. S pecialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists r ated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate, Generalists and specialists failed to agree on the avoida bility of 34% of referrals. CONCLUSIONS: Generalists made most referrals for a combination of medical a nd nonmedical reasons, and many referrals were considered avoidable. Increa sing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.