Good Referral Practices – Dr Chua Li-Shun

stock-footage-doctor-and-nurse-discussing-xray-in-office-at-the-hospitalA 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:

  1. 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.
  2. Remember the purpose of a referral/presentation is to communicate the reasons for the diagnosis and rationalisation behind the course of treatment taken.
  3. Consider the complexity of the case, the context and who the listener is.
  4. 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!
  5. Present relevant points (both positive and negative) in the patient’s history and physical examination first, taking care not to omit the vital signs.
  6. 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.
  7. 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:

  1. Use appropriate stationery, like official letterheads.
  2. Write legibly.
  3. Identify yourself and the reason the patient was in your care.
  4. Include a list of known allergies and current medications.
  5. 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.] 

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