Referral

(Source: Family Medicine Ian McWhinney)

Referral implies a transfer of responsibility for some aspect of the patient’s care. For the family
physician, the transfer of responsibility is never total, for he or she always retains an overall
responsibility for the patient’s welfare. Even if the patient is having major surgery in some distant
medical center, the family physician should still be available to patient, family, and surgeon.

The division of responsibility between referring physician and specialist must be clearly defined. This is
made easier by defining the different types of referral:

1. Interval referral.

The patient is referred for complete care for a limited period. The referring physician has no
responsibilities during this period except those described above. A common example is the referral of a
patient for major surgery or a major medical illness. It is essential to good care that after referral only
the specialist should prescribe treatment. The family physician should advise and comment, but not
order treatment unless asked to do so. This situation may arise, for example, if a patient develops a
respiratory infection, skin rash, or mental breakdown following surgery. In these circumstances it would
be natural for the surgeon to ask for the family physician’s advice as a consultant with special knowledge
of the patient and skill in dealing with common disorders.

2. Collateral referral.

The referring physician retains overall responsibility, but refers the patient for care of some specific
problem. The referral may be long term, as for chronic glaucoma, or short term, as for counseling for a
psychological or social problem.

3. Cross-referral.

The patient is advised to see another physician, and the referring physician accepts no further
responsibility for the patient’s care. This may occur after self-referral by the patient or even after
referral by a family physician. In either case, the practice must be condemned, because it is wasteful of
resources, demoralizing for the patient, and alienating for the family physician. If a consultant feels that
another specialist’s opinion is required, he or she should so inform the referring physician before making
any referral himself or herself.

4. Split referral.

This takes place under conditions of multispecialist practice, when responsibility is divided more or less
evenly between two or more physicians, such as one for the patient’s diabetes, another for his ischemic
heart disease. The danger of this type of care is that nobody knows who has overall responsibility for the
patient.
The danger of fragmented care is division of responsibility. This can all too easily lead to what Balint
(1964) has called the “collusion of anonymity.” This refers to decisions being made about a patient’s
management without a clear understanding of who is responsible for them. Although teamwork is
necessary for good patient care, teams should not make decisions. It should always be clear who is
responsible to the patient for clinical decisions.