A common complaint from secondary and tertiary medical centres is the declining quality of inter-hospital and interdisciplinary referrals. Although junior doctors are often blamed, it would be unfair to dismiss the fact that communication between medical personnel on all levels is a dying art.
There are many speculations to the source of this problem. Greater access to healthcare means a referral letter, well-written or otherwise, is sufficient to grant a patient a specialist consultation. The prevalence of medical negligence suits has caused doctors to take a defensive approach to medicine, opting to review every referral in person instead of relying on the message conveyed by the referring person to decide on a plan of management. This renders the referral itself redundant and gives no incentive to the referrer to perfect his or her presentation.
However, a good referral makes a world of difference in a patient’s management because it conveys the diagnostic reasoning to the listener, therefore helping to formulate a management plan. Effective communication is the key to good clinical practices and is a skill all healthcare personnel should strive to improve.
A good medical referral starts with good habits as a student. Here are some tips for medical students and junior doctors when presenting a case:
- It goes without saying that thorough history taking, physical examination, review of relevant investigations and understanding of the patient’s problems are prerequisites to making a referral.
- Remember the purpose of a referral/presentation is to communicate the reasons for the diagnosis and rationalisation behind the course of treatment taken.
- Consider the complexity of the case, the context and who the listener is.
- Start off with a standard one-line introduction of the patient’s demographic (name, age, occupation, comorbidities), then a one-sentence summary of the patient’s presenting complaint – don’t forget the duration!
- Present relevant points (both positive and negative) in the patient’s history and physical examination first, taking care not to omit the vital signs.
- Interpret investigation results before presenting them – this shows your clinical acumen and allows the listener to get a better picture of your patient’s condition.
- End with a summary of the patient’s problems and issues that warrant the referral.
The same principles apply when writing a referral letter. A succinct letter should not exceed one page in length. Some additional guidelines are as below:
- Use appropriate stationery, like official letterheads.
- Write legibly.
- Identify yourself and the reason the patient was in your care.
- Include a list of known allergies and current medications.
- Be as specific as possible when stating the reason for referral.
In summary, the key to a good verbal or written referral is in your understanding of the patient’s problems and reasons for referral. A well-presented referral can help formulate an appropriate and effective management plan, leading to a better treatment outcome. Don’t be afraid to make mistakes and always strive to learn from them. As the saying goes, practice makes perfect!
Dr. Chua Li-Shun is a medical officer working in Selangor and also an editor for the Malaysian Medical Gazette.
References:
- Olaitan A, Okunade O, Corne J. How to present clinical cases. Student BMJ 2010;18:c1539
- The Royal Australian College of General Practitioners. Referral documents. http://www.racgp.org.au/your-practice/standards/standards4thedition/practice-services/1-6/referral-documents/
[This article belongs to The Malaysian Medical Gazette. Any republication (online or offline) without written permission from The Malaysian Medical Gazette is prohibited.]