Under what circumstance might a physician refer a patient to another physician for a consultation?

Preamble

This professional standard specifies the College’s requirements of physicians regarding an effective referral and consultation process for those patients with a primary care physician or other provider.

Referring physicians and consulting physicians have a professional and ethical obligation to share the responsibility of supporting patients through the referral- consultation process.

Professional Standards

1. Professional communication between referring and consulting physicians must always serve the best interests of patients and should be respectful, collegial, collaborative and courteous.
2. Consulting physicians must:
   1. Ensure they have a system in place to prioritize patients according to the level of urgency of their condition. Objective criteria should be used to assist in this screening process so that it is done in a consistent and non-arbitrary manner.
3. Referring physicians must:
   1. Only refer a patient to one consultant at a time within a discipline for a specific problem.
   2. Act upon a patient’s request for referral to another health care provider for a second opinion providing the physician considers the request to be reasonable.
   3. Provide a consultation request in writing, unless circumstances prevent, which includes:
      1. The specific reason(s) for the consultation request;
      2. Accurate contact information (including address and phone number), basic demographic information about the patient (such as gender and age) and the patient’s Nova Scotia Health Card (MSI) number and/or insurance information;
      3. The referring physician’s contact information (including address, phone number, and/or pager number);
      4. The referring physician’s expectations of what the consultant will undertake, when possible. For example, whether the request is for an assessment and advice only or whether there is a request to transfer some or all of the responsibility for care;
      5. A summary of pertinent medical history, examination findings, current medications (name and dosage used, including those on a PRN basis), known allergies, and the identification of other physicians currently involved in the patient’s care, where appropriate; and
      6. Informing the consultant if the estimated wait time is inappropriately long for the patient’s condition, or if the patient’s condition changes during the wait period. The referring physician should also consider referring the patient to another consultant if the clinical condition of the patient requires an earlier appointment than the consultant can accommodate.
      7. After the referral has been sent and before the patient has been seen, must inform the consultant about clinically relevant changes in the patient`s condition or treatment.
   4. After the referral has been sent and before the patient has been seen, must inform the consultant about clinically relevant changes in the patient`s condition or treatment.
4. After receiving a consultation request, the consulting physician must:
   1. Provide a prompt response to the referring physician or nurse practitioner within 14 days acknowledging the referral and anticipated wait time or appointment date by fax or encrypted e-mail.  When a firm appointment date cannot be provided, this acknowledgment must be supplied, along with an estimated appointment date.  Confirmation of actual appointment date must be provided when known;
   2. Schedule the appointment directly with the patient, except in exceptional circumstances. For example, exceptions exist in the case of diagnostic specialties, such as Radiology.  See “The Case of Diagnostic Specialties” below).
   3. Advise the patient of any specific requirements prior to the appointment (e.g. bowel preparations, fasting, etc.).
   4. Advise the patient to contact the consultant or referring physician or nurse practitioner if there is any change in his/her condition.
   5. Communicate expectations about office procedures and policies to the patient (e.g. cancellations or confirming appointments in advance).
5. After seeing the patient, the consultant must:
   1. Provide the referring physician, family physician or nurse practitioner (or other primary care provider if applicable) with a timely written report that includes, but is not limited to:
      1. Relevant history and findings of examinations;
      2. Conclusions regarding diagnosis (definitive/provisional, differential diagnosis where appropriate);
      3. Diagnostic and therapeutic interventions that were implemented and/or recommended;
      4. Outline all plans for consultant follow-up with the patient; and
      5. Provide the referring physician or nurse practitioner a follow-up report upon every visit if he/she sees the patient for an extended period of time.
   2. In the event the consulting physician is unable to generate a written report within 14 days of the patient encounter, the consulting physician must contact the referring physician, family physician or nurse practitioner directly to advise of the outcomes of the patient encounter.
6. The physician who orders diagnostic testing is responsible for following up on the testing.
7. The Case of Diagnostic Specialties
   1. When referring or consulting with a diagnostic specialty such as diagnostic radiology or laboratory pathology, the following information must be provided:
      1. Accurate contact information (including address and phone number), basic demographic information about the patient (such as gender and age) and the patient’s Nova Scotia Health Card (MSI) number and/or insurance information;
      2. The name of all physicians or health care providers to whom copies of the reports should be sent;
      3. A brief clinical history or presumptive diagnosis; and
      4. An indication of the urgency for the examination to assist in prioritization.
   2. Physicians who work in diagnostic specialties, such as diagnostic radiology or laboratory pathology, function in a consultative capacity with family practitioners and other specialists.  As such, they are responsible for ensuring the following:
      1. Prompt acknowledgment of requests from referring physicians or nurse practitioners;
      2. Prompt communication to referring physicians or nurse practitioners of anticipated wait times;
      3. Confirmation of referral and appointment times to the consultant. (If the examination is to be performed within 48 hours, the contact should be made with the patient directly); and
      4. Provision of timely reports.

Questions and answers to assist in application of the Standard

1. I have little or no managerial influence over my office staff because they are employees of the institution in which I work. How can I comply with this standard given that the roles and activities of my office staff are so critical to the referral process?
   Administrative or systemic failures do not mitigate your responsibility to the patient.  When confronted by such failings, physicians are encouraged to contact each other directly.
2. My referral depends on the availability of diagnostic imaging, pathology services, or other third-party services over which I have no control. How can I comply with this standard given that so much of the process is out of my hands?
   Limits on diagnostic resources are an unfortunate reality of today’s medical environment.  Despite these limitations, patients are entitled to know the approximate date of services ordered on their behalf.
3. As a specialist, I often see consultation requests containing little or no information. An example is “Chest pain – please assess”. What can I do about inadequate requests like this?
   Referrals of this nature clearly fail to meet the provisions of this standard. Referring physicians are expected to provide complete, clear referral information. In the example provided, the consulting physician could not possibly triage the request appropriately.  In the interest of both your patients and your peers, you may wish to raise your concerns in a collegial manner with the referring physician.
4. I am a family physician. I recently referred a patient to a local specialist. The consultation letter I received from the specialist recommended that the patient be started on a particular medication.  When I later saw the patient, I discovered that she had been taking the medication since seeing the specialist. How can such miscommunication be prevented?
   Notes sent from consultants should always distinguish between interventions that were initiated by the consultant and interventions that the consultant advised the referring physician to initiate.

Document History

Revised and approved by the Council of the College of Physicians and Surgeons on March 29, 2019.

Re-approved by the Council of the College of Physicians and Surgeons of Nova Scotia on December 13, 2013. First Approved by the Council of the College of Physicians and Surgeons of Nova Scotia on March 26, 2010

Date of next review: 2022