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Journal of General Internal Medicine

, Volume 14, Issue 5, pp 281–286 | Cite as

Reasons for outpatient referrals from generalists to specialists

  • Martin T. Donohoe
  • Richard L. Kravitz
  • David B. Wheeler
  • Ravi Chandra
  • Alice Chen
  • Natasha Humphries
Original Articles

Abstract

OBJECTIVE: To determine the relative importance of medical and nonmedical factors influencing generalists’ decisions to refer, and of the factors that might avert unnecessary referrals.

DESIGN: Prospective survey of all referrals from generalists to subspecialists over a 5-month period.

SETTING: University hospital outpatient clinics.

PARTICIPANTS: Fifty-seven staff physicians in general internal medicine, family medicine, dermatology, orthopedics, gastroenterology, and rheumatology.

MEASUREMENTS AND MAIN RESULTS: For each referral, the generalist rated a number of medical and nonmedical reasons for referral, as well as factors that may have helped avert the referral; the specialist seeing the patient then rated the appropriateness, timeliness, and complexity of the referral. Both 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 in 20%, and by only nonmedical reasons in 3%. In 33% of all referrals, generalists felt that training in simple procedures or communication with a generalist or specialist colleague would have allowed them to avoid referral. Specialists felt that the vast majority of referrals were timely (as opposed to premature or delayed) and of average complexity. Although specialists rated most referrals as appropriate, 30% were rated as possibly appropriate or inappropriate. Generalists and specialists failed to agree on the avoidability of 34% of referrals.

CONCLUSIONS: Generalists made most referrals for a combination of medical and nonmedical reasons, and many referrals were considered avoidable. Increasing procedural training for generalists and enhancing informal channels of communication between generalists and subspecialists might result in more appropriate referrals at lower cost.

Key words

generalist specialist referral outpatients 

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Copyright information

© Society of General Internal Medicine 1999

Authors and Affiliations

  • Martin T. Donohoe
    • 1
  • Richard L. Kravitz
    • 3
  • David B. Wheeler
    • 2
  • Ravi Chandra
    • 2
  • Alice Chen
    • 2
  • Natasha Humphries
    • 4
  1. 1.the Robert Wood Johnson Clinical Scholars ProgramUSA
  2. 2.Stanford University School of MedicineStanford
  3. 3.Division of General Internal MedicineUniversity of California at Davis School of MedicineDavis
  4. 4.Stanford UniversityStanford

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