Query

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. Looking back, I was probably quite bad at this, talking too long to say pertinent details, digressing, repeating physical findings … more than once I was cut off and simply asked the name and location of the patient.

Figure. Photo by: Fred Sebastian

I've since gotten better at the art of referral. And though it took a long time to grasp, the formula was actually quite simple: say the patient name first, then age, then where I'm calling from, then the reason for the consult (query appendicitis, say, or query Guillain–Barré), and finally a streamlined history and the positive results of a physical exam.

So when a sick patient comes into my office needing my help, and it turns out they need more help than I can provide, I in turn ask for help from specialists. And I can honestly declare that most of them have been attentive, collegial, complementary and very accommodating at seeing our sick patient at the soonest possible moment. My appendicitis-es and Guillain–Barrés and complicated fractures get seen the same day, as they should be. Yet every once in a while — it just happened last week — I encounter a new specialist, one I haven't met, shaken hands with or presented to before. And in this special circumstance the attitude I meet on the phone is one I have come to detest. The attitude is: go away, you're bothering me. And the attitude oozes into the silences and pauses, it leaks from the phone like radiation. Such specialists ask for silly details in order to put you off balance, enquiring about trivia such as adductor pain and a psoas sign when the history and abdominal exam is classic for appendicitis; or asking for tuning fork vibrational sense when it's clear the patient has loss of distal muscle tone and sensation. Asking a battery of such irrelevant questions is designed to make the family physician feel remiss, to establish a power differential (I ask the questions around here; you answer them). The bottom line is: I think that my patient needs to be seen by the consultant, and I feel that that really should be enough. I'm open to CME, but it shouldn't come in the form of knowledge abuse. I know that the specialist is entitled to ask questions, in fact should ask questions, in order to better triage and differentiate the case; yet such a process should be devoid of making the family physician squirm for perverse enjoyment. Some of those I consult are indeed very busy, far busier than me; the wait to see a neurologist in my neck of the woods is over one year. Yet the backlog isn't an excuse for such behaviour.

I've dealt with this problem long enough to have developed a strategy when a consult seems to be going awry. Now when I start to get sucked into that FP–consultant vortex (a place where patient concerns seem to get lost) I interrupt the interrogation and say, “Dr. X, I'm sorry, but we seem to have gotten 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 serious enough that you should see this patient. I'm worried about him.”

As soon as I communicate to the consultant that I'm worried about the patient, the tone of the conversation changes. Then it becomes a pleasure for them to see the patient, not a chore, and I actually get thanked for making the referral. And I think this is because the one frontier where physicians can unite is our concern for our patients.

— Dr. Ursus