I can remember my time in medical school — decidedly unhalcyon days — when, at the behest of my attending, I, a lowly clerk, would call specialists in the hospital and ask them to see patients on our ward. I was quite bad at this. I took too long to give pertinent details, digressed, repeated physical findings … more than once I was cut off and asked to simply give the name and location of the patient. Click.
Figure. Photo by: Anson Liaw
I've since gotten better at the art of referral. The formula is actually quite simple: say the patient's name first, then his or her age, then where I'm calling from, then the reason for the consult (query appendicitis, say, or query Guillain–Barré) and then give a streamlined history and any positive findings on physical exam.
This approach usually works; I can honestly say that most specialists I call are attentive, collegial and accommodating at seeing our sick patient at the soonest possible moment. My appendicitises and Guillain–Barrés and complicated fractures get seen the same day, as they should be. Yet every once in a while I encounter an attitude I've come to detest. The attitude is: Go away, I'm too busy for this.
This attitude oozes into silences and pauses; it leaks from the phone like radiation. Such specialists ask for silly details to put you off balance, enquiring about trivia like adductor pain and a psoas sign when the history and abdominal exam are classic for appendicitis, or for tuning-fork vibrational sense when it's clear the patient has loss of distal muscle tone and sensation. Or they ask a battery of irrelevant questions designed to make you feel remiss and confirm a power differential: I ask the questions around here, you answer them.
My bottom line is this: I think my patient needs to be seen by the consultant, and that really should be enough. I'm open to CME but it shouldn't come in the form of knowledge abuse. I know the specialist is entitled to ask questions, and should ask questions, to better triage and differentiate the case; yet such a process should not involve taking perverse enjoyment in making the family physician squirm. Some of those I consult are indeed very busy, far busier than me; the wait to see a neurologist in my environs is over a year. Yet the backlog isn't an excuse for such behaviour.
I've dealt with this problem long enough to develop a strategy to salvage consults that start to go awry. Now I say, “Dr. X, I'm sorry, but we seem to have got off on the wrong foot. I don't call you very often, and I never call unless I think there is something wrong. If I thought this could wait, then I would have tried to book the patient into your clinic. But I think the problem is worrying enough that you should see this patient now.”
As soon as I communicate that I am worried about the patient, the tone of the conversation changes. It lifts us both out of the FP–consultant vortex and onto common ground: concern for the patient, the frontier on which all physicians can unite. — Dr. Ursus
