Journal of General Internal Medicine

, Volume 15, Issue 9, pp 626–631 | Cite as

Communication breakdown in the outpatient referral process

  • Tejal K. Gandhi
  • Dean F. Sittig
  • Michael Franklin
  • Andrew J. Sussman
  • David G. Fairchild
  • David W. BatesEmail author
Original Articles


OBJECTIVE: To evaluate primary care and specialist physicians’ satisfaction with interphysician communication and to identify the major problems in the current referral process.

DESIGN: Surveys were mailed to providers to determine satisfaction with the referral process; then patient-specific surveys were e-mailed to this group to obtain real-time referral information.

SETTING: Academic tertiary care medical center.

PARTICIPANTS: Attending-level primary care physicians (PCPs) and specialists.

MEASUREMENTS AND MAIN RESULTS: The response rate for mail surveys for PCPs was 57% and for specialists was 51%. In the mail survey, 63% of PCPs and 35% of specialists were dissatisfied with the current referral process. Respondents felt that major problems with the current referral system were lack of timeliness of information and inadequate referral letter content. Information considered important by recipient groups was often not included in letters that were sent. The response rate for the referral specific e-mail surveys was 56% for PCPs and 53% for specialists. In this e-mail survey, 68% of specialists reported that they received no information from the PCP prior to specific referral visits, and 38% of these said that this information would have been helpful. In addition, four weeks after specific referral visits, 25% of PCPs had still not received any information from specialists.

CONCLUSIONS: Substantial problems were present in the referral process. The major issues were physician dissatisfaction, lack of timeliness, and inadequate content of interphysician communication. Information obtained from the general survey and referral-specific survey was congruent. Efforts to improve the referral system could improve both physician satisfaction and quality of patient care.

Key Words

ambulatory care communication referral and consultation 


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  1. 1.
    Epstein RM. Communication between primary care physicians and consultants [see comments]. Arch Fam Med. 1995;4:403–9.PubMedCrossRefGoogle Scholar
  2. 2.
    Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74:106–12.PubMedCrossRefGoogle Scholar
  3. 3.
    Cummins RO, Smith RW, Inui TS. Communication failure in primary care. Failure of consultants to provide follow-up information. JAMA. 1980;243:1650–2.PubMedCrossRefGoogle Scholar
  4. 4.
    Bourguet C, Gilchrist V, McCord G. The consultation and referral process. A report from NEON. Northeastern Ohio Network Research Group. J Fam Pract. 1998;46:47–53.PubMedGoogle Scholar
  5. 5.
    Newton J, Eccles M, Hutchinson A. Communication between general practitioners and consultants: what should their letters contain?. BMJ. 1992;304:821–4.PubMedCrossRefGoogle Scholar
  6. 6.
    Butow PN, Dunn SM, Tattersall MH, Jones QJ. Computer-based interaction analysis of the cancer consultation. Br J Cancer. 1995;71:1115–21.PubMedGoogle Scholar
  7. 7.
    Williams PT, Peet G. Differences in the value of clinical information: referring physicians versus consulting specialists. J Am Board Fam Pract. 1994;7:292–302.PubMedGoogle Scholar
  8. 8.
    McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144:1265–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Graham PH. Improving communication with specialists. The case of an oncology clinic. Med J Aust. 1994;160:625–7.PubMedGoogle Scholar
  10. 10.
    Jenkins RM. Quality of general practitioner referrals to outpatient departments: assessment by specialists and a general practitioner. Br J Gen Pract. 1993;43:111–3.PubMedGoogle Scholar
  11. 11.
    Teich J, Glaser J, Beckley RF, et al. Toward cost-effective, quality care: the Brigham Integrated Computing System. Proc. 2nd Nicholas E. Davies CPR Recognition Symposium. 1996;3–34.Google Scholar
  12. 12.
    Leape LL, Bates DW, Cullen DJ, et al. Systems analysis of adverse drug events. JAMA. 1995;274:35–43.PubMedCrossRefGoogle Scholar
  13. 13.
    Moosbrugger MC: Unclogging the physician referral network. Winning referrals requires research and tracking. Healthcare Exec. 1988;3:28–9.Google Scholar
  14. 14.
    Donohoe MT, Kravitz RL, Wheeler DB, Chandra R, Chen A, Humphries N. Reasons for outpatient referrals from generalists to specialists. J Gen Intern Med. 1999;14:281–6.PubMedCrossRefGoogle Scholar
  15. 15.
    Hansen JP, Brown SE, Sullivan RJJ, Muhlbaier LH. Factors related to an effective referral and consultation process. J Fam Pract. 1982;15:651–6.PubMedGoogle Scholar
  16. 16.
    Roulidis ZC, Schulman KA. Physician communication in managed care organizations: opinions of primary care physicians. J Fam Pract. 1994;39:446–51.PubMedGoogle Scholar

Copyright information

© Society of General Internal Medicine 2000

Authors and Affiliations

  • Tejal K. Gandhi
    • 1
  • Dean F. Sittig
    • 2
  • Michael Franklin
    • 2
  • Andrew J. Sussman
    • 1
  • David G. Fairchild
    • 1
  • David W. Bates
    • 1
    Email author
  1. 1.the Division of General Internal Medicine, Brigham and Women’s HospitalHarvard Medical SchoolBoston
  2. 2.Clinical Systems Research and DevelopmentPartners Healthcare SystemBoston

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