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


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 


Unable to display preview. Download preview PDF.

Unable to display preview. Download preview PDF.


  1. 1.
    Mayer TR. Family practice referral patterns in a health maintenance organization. J Fam Pract. 1982;14(2):315–9.PubMedGoogle Scholar
  2. 2.
    Schmidt DD. Referral patterns in an individual family practice. J Fam Pract. 1977;5(3):401–3.PubMedGoogle Scholar
  3. 3.
    Geyman JP, Brown TC, Rivers K. Referrals in family practice: a comparative study by geographic region and practice setting. J Fam Pract. 1976;3(2):163–7.PubMedGoogle Scholar
  4. 4.
    Ludke RL. An examination of the factors that influence patient referral decisions. Med Care. 1982;20(8):782–96.PubMedCrossRefGoogle Scholar
  5. 5.
    Schaffer WA, Holloman FC Jr. Consultation and referral between physicians in new medical practice environments. Ann Intern Med. 1985;103(4):600–5.PubMedGoogle Scholar
  6. 6.
    Tenney JB, Brown TC, Rivers K. National ambulatory medical care survey: background and methodology. Vital Health Stat 2. 1974;61:74–1335.Google Scholar
  7. 7.
    Franks P, Clancy CM, Nutting PA. Defining Primary Care. Empirical analysis of the National Ambulatory Care Survey. Med Care. 1997;35(7):655–68.PubMedCrossRefGoogle Scholar
  8. 8.
    Schneeweiss R, Ellsbury K, Hart LG, Geyman JP. The economic impact and multiplier effect of a family practice clinic on an academic medical center. JAMA. 1989;262(3):370–5.PubMedCrossRefGoogle Scholar
  9. 9.
    Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106–12.PubMedCrossRefGoogle Scholar
  10. 10.
    Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267(12):1624–30.PubMedCrossRefGoogle Scholar
  11. 11.
    Brock C. Consultation and referral patterns of family physicians. J Fam Pract. 1977;4(6):1129–37.PubMedGoogle Scholar
  12. 12.
    Calman NS, Hyman RB, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35(1):31–8.PubMedGoogle Scholar
  13. 13.
    Gonzalez ML, Rizzo JA. Physician referrals and the medical market place. Med Care. 1991;29(10):1017–27.PubMedCrossRefGoogle Scholar
  14. 14.
    Penchansky R, Fox D. Frequency of referral and patient characteristics in group practice. Med Care. 1970;8(5):368–85.PubMedGoogle Scholar
  15. 15.
    Pearson SD, Salem-Schatz S, Rucker M, Orav EJ, Pedan A. Variation in referral rates for acute low back pain in an HMO. J Gen Intern Med. 1995;10(suppl 4):76. Abstract.Google Scholar
  16. 16.
    Metcalfe DH, Sischy D. Patterns of referral from family practice. J Fam Pract. 1974;1(2):34–8.PubMedGoogle Scholar
  17. 17.
    Pearson SD, Salem-Schatz S, Rucker M, Orav EJ, Pedan A. HMO physician correlates of referral for acute low back pain. J Gen Intern Med. 1995;10(suppl 4):76. Abstract.Google Scholar
  18. 18.
    Strohmeyer RW Jr, Shula RJ. Physician’s liability for failure to consult with and/or refer a patient to a specialist. Indiana Med. 1988;81(1):45–7.PubMedGoogle Scholar
  19. 19.
    Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314(8):512–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Braham RL, Ron A, Ruchlin HS, Hollenberg JP, Pompei P, Charlson ME. Diagnostic test restraint and the specialty consultation. J Gen Intern Med. 1990;5(2):95–103.PubMedCrossRefGoogle Scholar
  21. 21.
    Kahn KL, Kosecoff J, Chassin MR, Solomon DH, Brook RH. The use and misuse of upper gastrointestinal endoscopy. Ann Intern Med. 1988;109(8):664–70.PubMedGoogle Scholar
  22. 22.
    Winslow CM, Kosecoff JB, Chassin M, Kanouse DE, Brook RH. The appropriateness of performing coronary artery bypass surgery. JAMA. 1988;260(4):505–9.PubMedCrossRefGoogle Scholar
  23. 23.
    Berczeller PH. The malignant consultation syndrome. Hosp Pract (Off Ed). 1991;26(9):29–31.Google Scholar
  24. 24.
    Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326(16):1080–4.PubMedCrossRefGoogle Scholar
  25. 25.
    Kashner TM, Rost K, Smith GR, Lewis S. An analysis of panel data: the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care. 1992;30(9):811–21.PubMedCrossRefGoogle Scholar
  26. 26.
    O’Dell MW. Rehabilitation medicine consultation in persons hospitalized with AIDS: an analysis of thirty cases. Am J Phys Med Rehabil. 1993;72(2):90–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Turner BJ, McKee L, Fanning T, Markson LE. AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact on hospital use. Med Care. 1994;32(9):902–16.PubMedCrossRefGoogle Scholar
  28. 28.
    Bloomfield S, Farquhar JW. Is a specialist paediatric diabetic clinic better? Arch Dis Child. 1990;65(1):139–40.PubMedGoogle Scholar
  29. 29.
    Ward MM, Leigh JP, Fries JF. Progression of functional disability in patients with rheumatoid arthritis: associations with rheumatology subspecialty care. Arch Intern Med. 1993;153(19):2229–37.PubMedCrossRefGoogle Scholar
  30. 30.
    Hooker RS, Brown JB. Rheumatology referral patterns. HMO Pract. 1990;4(2):61–5.PubMedGoogle Scholar
  31. 31.
    Hickam DH, Smith SP, Joos SK. Natural history and management of psychologic problems in a general medicine clinic. J Gen Intern Med. 1994;9(suppl 2):56. Abstract.Google Scholar
  32. 32.
    Menken M, Behar R, Lee P. Neurology referral patterns. HMO Pract. 1990;4(2):57–60.PubMedGoogle Scholar
  33. 33.
    Grembowski DE, Cook K, Patrick DL, Roussel AE. Managed care and physician referral. Med Care Res Rev. 1998;55(1):3–31.PubMedCrossRefGoogle Scholar
  34. 34.
    Chao J, Galazka S, Stange K, Fedirko T. A prospective review system of nonurgent consultation requests in a family medicine residency practice. Fam Med. 1993;25(9):570–5.PubMedGoogle Scholar
  35. 35.
    Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? BMJ. 1998;297(6648):599–600.Google Scholar
  36. 36.
    Friedman E. Whither medical education? A sometimes inflexible system faces change. JAMA. 1993;270(12):1473–6.PubMedCrossRefGoogle Scholar
  37. 37.
    Sick People in Managed Care Have Difficulty Getting Services and Treatment. New Survey Reports, Robert Wood Johnson Foundation, June 28, 1995.Google Scholar
  38. 38.
    Doyle RL. Section B—primary care guidelines. In: Healthcare Management Guidelines. Milliman and Robertson; 1991.Google Scholar
  39. 39.
    Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract. 1991;32(2):167–74.PubMedGoogle Scholar
  40. 40.
    Cain JM, Jonsen AR. Specialists and generalists in obstetrics and gynecology: conflicts of interest in referral and an ethical alternative. Womens Health Issues. 1992;2(3):137–45.PubMedCrossRefGoogle Scholar
  41. 41.
    Langley GR, MacLellan AM, Sutherland HJ, Till JE. Effect of nonmedical factors on family physicians’ decisions about referral for consultation. Can Med Assoc J. 1992;147(5):659–66.Google Scholar
  42. 42.
    Fitzpatrick R, Hopkins A. Referrals to neurologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry. 1981;44(12):1061–7.PubMedGoogle Scholar
  43. 43.
    Greenfield S, Linn LS, Purtill N, Young RT. Reverse consultations: the profiles of patients referred from subspecialists to generalists. J Chronic Dis. 1983;36(12):883–9.PubMedCrossRefGoogle Scholar
  44. 44.
    Leonard I, Babbs C, Creed F. Psychiatric referrals within the hospital—the communication process. J R Soc Med. 1990;83(4):241–4.PubMedGoogle Scholar
  45. 45.
    Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905–9.PubMedCrossRefGoogle Scholar
  46. 46.
    Keating NL, Zaslavsky AM, Ayanian JZ. Physicians’ experiences and beliefs regarding informal consultation. JAMA. 1998;280(10):900–4.PubMedCrossRefGoogle Scholar
  47. 47.
    Hjortdahl P, Borchgrevnik CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ. 1991;303(6811):1181–4.PubMedGoogle Scholar
  48. 48.
    Armstrong D, Fry J, Armstrong P. Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302(6786):1186–8.PubMedCrossRefGoogle Scholar
  49. 49.
    Eisenberg JM. Physician utilization: the state of research about physicians’ practice patterns. Med Care. 1985;23(5):461–83.PubMedCrossRefGoogle Scholar
  50. 50.
    Marton KI, Sox HC Jr, Wasson J, Duisenberg CE. The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med. 1980;140(2):191–5.PubMedCrossRefGoogle Scholar
  51. 51.
    Lin CT, Albertson G, Swaney R, Anderson S, Anderson R. Patient expectations for subspecialty referral in an academic managed care system. J Gen Intern Med. 1998;13(suppl):65. Abstract.Google Scholar
  52. 52.
    Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75–81.PubMedCrossRefGoogle Scholar
  53. 53.
    Byrd JC, Moskowitz MA. Outpatient consultation: interaction between the general internist and the specialist. J Gen Intern Med. 1987;2(2):93–8.PubMedCrossRefGoogle Scholar
  54. 54.
    McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144(6):1265–8.PubMedCrossRefGoogle Scholar
  55. 55.
    Cummins RO, Smith RW, Inui TS. Communication failure in primary care: failure of consultants to provide follow-up information. JAMA. 1980;243(16):1650–2.PubMedCrossRefGoogle Scholar
  56. 56.
    Lloyd M, Bradford C, Webb S. Non-attendance at outpatient clinics: is it related to the referral process? Fam Pract. 1993;10(2):111–7.PubMedCrossRefGoogle Scholar
  57. 57.
    Mantyjarvi M. No-show patients in an ophthalmological out-patient department. Acta Ophthalmol (Copenh). 1994;72(3):284–9.Google Scholar
  58. 58.
    Ross JD, McIver A, Blakely A, Dalrymple J, Peacock W, Wallis C. Why do patients default from follow-up at a genitourinary clinic?: a multivariate analysis. Genitourin Med. 1995;71(6):393–5.PubMedGoogle Scholar

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

Personalised recommendations