This will be the first in an occasional series of posts aimed at optimal referrals to our specialists. At PHC we deeply appreciate the specialists who see our patients. We pay specialists significantly better than state fee-for-service rates, but we cannot match the rates of private insurance. Because of this, we want to optimize the valuable services and treatments provided by our specialists. THANK YOU, SPECIALISTS.

• No-Shows – Perhaps more than any factor, no-shows can bury the system. Specialists may bail out of PHC if there are too many no-shows. Who can blame them? No-shows dishearten specialists. The same valuable appointment slot could have been used for another patient. Obviously the referring primary care clinician cannot guarantee that a patient will show up at the specialist’s office, but you can help by emphasizing to the patient the importance of arriving a little before the scheduled appointment time. If it turns out they can’t make the appointment, ask them to please cancel early, very early. If the patient has frequently no-showed in your office, that increases the risk they will no-show at the specialist’s office. This situation may merit a frank discussion with the patient prior to placing the referral. If the patient does not understand why you feel they need to see a specialist, perhaps a direct talk with the patient about the importance of the referral can increase the likelihood they will keep the appointment. Recently, a specialist told me that five out of six of the last PHC member appointments were no-shows – yikes!
• Rhyme of the Ancient Mariner – We all have albatrosses weighing us down in clinic – slow, difficult, chronic, and with difficult-if-any solutions. We all know examples – chronic headache for the neurologist, chronic low back pain for the orthopedic surgeon, chronic testicular pain for the urologist, fibromyalgia for the pain specialist (for which narcotics are not indicated by the way). We know the list. Specialists are pretty courteous with these referrals but honestly… let’s do our best to refer those patients that can benefit from our specialist colleagues’ expertise. Let’s have them practicing at the top of their talents. Of course there will be times when difficult-to-mange patients need to be and will be referred to a specialist. One example is when a skeptical patient needs validation from an expert that the primary care doc’s treatment is correct. But for those frustrating patients with problems no one can resolve, only send them to see a specialist if you think the consultation will really make a difference in the patient’s care.
• Poorly prepared referrals – In the old pre-EHR days I remember writing a letter of referral to my specialist colleagues outlining the problem, workup and treatments to date, current medications, labs, and imaging if needed. Now – off to the referral coordinators (bless their souls) and a push of the button with a compilation of the last three visits (no matter what the content), labs, imaging, and off to the lucky receiving specialist. And what have I heard from specialists? “I get a stack of paper, visits with multiple medical conditions addressed. I have to cull out that which might be the issue at hand. Find the pertinent details of what has been done to date. Find the relevant labs and imaging. And, finally, what is the actual question I’m supposed to answer?”  These are valid questions, and our referral coordinators cannot do this job for us. Some offices have a well versed clinician review every referral before sending.
• The shiny apple vs. one bad apple can spoil the bunch – I’ve always wanted my referral to be so polished up that the specialist is pointed in the right direction. One visit and done. What can I do to reduce, if possible, the need for another appointment to follow up a lab or imaging study ordered by the specialist? Essentially, one visit for the price of two. Though I am a primary care physician, I also do some work as a specialist evaluating hepatitis C patients. In that role, I have gotten referrals where the only information offered as the reason for the referral is “Positive HCV test.” No other information has been obtained. There is no confirmatory HCV viral load measurement. So as the “specialist” I have to see the patient twice, where one visit should have done the job.

Whaddya think? More to come but I’m blogged out for the day.

Marshall Kubota, MD