FOAM4GP Map – Better referral letters – “Dear Neurologist, please see John ? head”

Letterkaartjes

“Dear Neurologist, please see John ?head. Sincerely, Dr AB.”

Referral letters are the way in which we can correspond our clinical information to our specialist colleagues. It is critically important and also reflects upon you as a clinician as to your medical skill and ability to be succinct.

It has been pointed out many times that GP letters to their specialist colleagues are often poor, and lacking key clinical information (sometimes ANY clinical information).

I wanted to highlight some important points about writing good letters and how we can do this better.

Issue 1: “Why do we even need to write good referral letters?”
I was asked recently “why do we need to write a good referral letter. The specialist will do it all again anyway.”

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Thanks to peebleslab.com

(Breathe Rob…) Now, apart from my then long winded rant about GPs gaining respect through demonstration of good clinical practices to our specialist colleagues etc. etc. Here are a few points.

1. “Why are you bothering to do anything if you expect the specialist to do it?”
Your thinking is backward. WE should be doing the hard work and working out the clinical problem AND THEN sending the pt to the specialist with specific instruction on where we would like their help. It is also insulting to the specialist that you didn’t take the time to work the pt up yourself.

2. Treat others as you would expect to be treated yourself.
I think my mother taught me this one (and your mother may have mentioned it to you!) Do you want the specialist to send you a one line response.

Letter: “Please review this knee for a possible operation.”
Reply: “It has been reviewed. Thank you for your kind and detailed referral.”

3. A patient cannot be triaged without clinical information
This is REALLY important. If you say:
“Please review this 63yo lady with chronic pelvic pain.”
And leave out she has had ongoing spotting for 7 woks and has had an US with a heterogeneous endometrial lining of 14mm thickness
These are VERY different referrals. Even if you didn’t know (in my gross example) that those details were important – the specialist should and will triage appropriately.

4. You may find out some detail which changes either your, or the specialists, view of the patient.
I tend to write my letters with the pt in the room with me. We work together on it. While I am writing I sometimes realise I had forgotten to ask some critical info which I then put in the letter.
Also, specialists can also forget to ask q’s sometimes. If the detail is in the letter this may help remind them about something important that you highlighted. For example: You may be sending a pt to a respiratory specialist for chronic cough. You might mention you had already trialled them on PPI for 4 wks with no improvement. Leave this out, and it’s no longer in the med chart, and you may find your patient back on PPI’s for 4 wks!

Issue 2: “I don’t have time to write detailed referrals”
I would argue a good referral is as important as taking a good history or exam. You wouldn’t skimp on those? Why skimp on appropriate handover of clinical information? If you have time issues these need to be addressed separately.

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Ok. So what’s in a GOOD referral letter?

1. Name of patient and contact details
Please check these are up to date with the patient! Does this need to be said?

2. Reason for referral (similar to “presenting complaint”)
This needs to be brief and succinct.
For example:

Mrs D is a 55yo F with an US demonstrating multiple gallstones on a background of chronic and debilitating RUQ pain. Please review this lady for possible cholecystectomy.

Mr T is a 35yo man with symptomatic Right ACL rupture 6 weeks ago when jumping out of a helicopter, confirmed on MRI, who is unhappy with his improvement with intensive physiotherapy. Would you please discuss with this gentleman any possible surgical options.

Ms Scarlet is a 23yo F who was in the library with the candlestick – please review this woman for incarceration. (I think you get the idea…)

ADDIT: you may want to put a line here as to whether the patient has private cover. Otherwise the whole letter may be read, triaged, and pt present and then not be able to be seen!

3. Background (or History of presenting complaint)

This needs detail which will influence clinical decisions Eg. Risk factors for cardiovascular disease in chest pain, B-symptoms in a patient with persistently elevated neutrophil count, or history of recent falls in patient with severe osteoporosis.

Investigations: Often useful to briefly summarise important positives and negatives of pathology/imaging

4. Impression:

I really like putting this in. Helps me clarify my thinking about what is going on and where I think next steps should go. Helps me also compare later how similar my thinking was to the specialist and outcomes.

"Hell" - Thanks to xkcd

“Hell” – Thanks to xkcd

5. Social History
The level of what is required obviously varies with presentation. For example:

A 83yo F being referred for work up to a geriatrician for cholinesterase inhibitors needs significant information about quality of life, functional status, home help levels, local supports etc.

A famous British soccer player, married to Posh Spice, being referred for a rhinoplasty may not need much information about his intelligence scores etc.

6. Past medical history – Most software puts this in.
Good to keep the list clean and up to date. Pt’s can get very upset when asked about their Chlamydia because the computer automatically put that in years ago when someone just did an STD screen! It also can misinform the specialist.

7. Medications

Once again critically important to be correct. Best to check with patient.

8. Allergies – of course (including type of reaction)
9. Smoking/alcohol/drugs – May be important

10. Signature and your contact details: Put in your full glorious name with all appellations, titles, and bloodlines.Your contact details: Don’t forget these if you do not have a letterhead.

2010-05-03-goldfish-II

Thanks to webdonuts

Want more information on this topic:

RACGP: Practice standards for referral letters – Link

Medicare: Requirements for referrals – Link

Australian Health Workforce Institute: Study looking at referral quality – They counted excellent referrals as ones that went to the right clinic and had intended outcome. Arguably I want to do better – Link

MJA: 2002 article discussing referral letter details and attempting to improve letters from a group of oncologists to GPs. Summarises literature on quality of referral letters both to and from GPs – Link

Australian Doctor – Brilliant GP Dr Genevieve Yates discussing the lighter side of referral letters and what may or may not be appropriate within – Link

Journal of general internal medicine 2000 – this article showed significant dissatisfaction between primary care physicians and physicians in outpatient setting – http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1495590/

Ireland – study suggested poor referral communication from GPs to specialists – http://hiqa.ie/system/files/gp_referral_report.pdf

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5 thoughts on “FOAM4GP Map – Better referral letters – “Dear Neurologist, please see John ? head”

  1. Great post, thanks Rob.
    My added response to those who claim they don’t have time for a detailed referral letter is “Then, consider not referring.”
    Instead, ask the patient to return, and it may be that with a bit more history, examination and thinking time, a management plan may become clearer, without requiring referral. If not, you now have a new appointment during with time to write.
    Like you, Rob, I prefer to write with the patient in the room, unless I’m snowed under or it’s really complex. Of course, sometimes that’s simply impractical. But I have to spend the same amount of time on the letter at some stage in my working day, regardless.

  2. It is a bit of a circular process – I, like many GPs, have a constant battle with our public and private Specialists to give us good and timely feedback. They usually compliment our clinic on our letters but the implication is that there are many referrals from elsewhere that are substandard and the Specialists are just responding in kind. I have repeatedly asked our local GPLUs if they give the GP culprits feedback but I doubt that they do – until then these clowns continue to give those that like to bag the quality of GP work ammo to shoot with. The problem is however also a system that rewards doctors for 6min consults, doctors who are content with bulkbilling incomes and a generation of doctors who deskill themselves by passing clinical care on to Noctors in their own Practices and elsewhere. This has bred a generation of GPs who are happy to be referologists, and bad ones at that, instead of thinking and acting as described in Rob’s post

  3. Lovely, as always, especially the bit about Ms Scarlett. My three additional pointers:

    (1) include recent consult notes that are relevant to the referral – will clarify your thought processes to the specialist. Cull the bits in those consults that are irrelevant.

    (2) when including relevant investigation results, I cull repetitive information. This happens when your referral letter imports from HL7 data and includes info like biodata which is repeated at the start of each result. Makes the referral more succinct.

    (3) use word processor formatting to highlight key information, especially if sending referrals electronically or by post – I use bold and caps in red for key phrases (e.g., LOST 10 KG UNINTENTIONALLY, LIVER CRAGGY AND TENDER) when emphasing urgency.

  4. Another fantastic post, Rob, thank you. Agree wholeheartedly with all you said. I’m going to share the link to your post with our registrars as it is an excellent summary, made more interesting with humour!
    (and thanks for the plug ;-))

  5. Pingback: Do you know what you don’t know? Want to find out? | FOAM4GP

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