GUIDELINE: Referral-Consultation Process

1. Preamble

The College recognizes that significant efforts have been made by other stakeholder organizations in Saskatchewan in formalizing expectations for referring and consulting physicians through the adoption of the Saskatchewan Quality Referral/Consult Pocket Checklist (the “Checklist”, attached as Appendix A, and “How to use” tips, attached as Appendix B). The College acknowledges that there is no single solution to address all of the potential communication challenges that may arise in the referral-consultation process. However, physicians should be mindful that patient well-being and safety remains the single most important factor in ensuring an effective referral-consultation process.

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

As a guideline, this document provides recommended practices as part of providing quality medical care in a professional manner. The College expects physicians to use their best judgment and exercise reasonable discretion in their decision-making based on this guideline. For example, in determining the most appropriate means of communication with patients who have been referred for a consultation, physicians must be mindful of privacy and other concerns that may make it inappropriate to send a letter directly to the patient in some circumstances.

2. Purpose and scope of this Guideline

This guideline is intended to help physicians understand their professional and ethical obligations when referring or accepting a patient for consultation. While the guideline references written referrals and consultation reports, it can also provide a useful reminder of the pertinent patient information to be provided when calling a consultant for advice or seeking an in-person consultation in a more acute setting.

Referrals and consultations occur across a very broad spectrum of care, including referrals from one primary care provider to another, from a primary care provider to a specialist, from a specialist to a specialist in a different discipline, from a specialist to a specialist within the same discipline, from a physician to a service, via an established referral pathway, etc. While this guideline cannot address each of those situations individually, it is intended to provide guidance to physicians involved in the referral-consultation process across the spectrum of care.

It is recognized that Nurse Practitioners often provide patient care. When this guideline references an expectation to communicate with the primary care provider or referring practitioner, that includes primary care physicians and Nurse Practitioners.

It is recognized that medical learners (students, post-graduate fellows and residents) may be involved in the referral-consultation process. This guideline applies to them as well.

3. Guiding principles

The following guiding principles are applicable:

Patients, caregivers and their families remain at the centre of the referral-consultation process. Referring and consulting physicians must communicate and collaborate professionally and respectfully to ensure patient care is not compromised and that the continuity of care is maintained throughout the referral - consultation process.
Keeping the patient informed throughout the referral process is essential and includes providing relevant expectations and directions to the patient regarding the process and expected timelines.
Good communication and collaboration between referring physicians and consulting physicians can prevent disruptions in care, delayed diagnoses, unnecessary testing, avoidable complications, frustration for physicians and patients, and can also potentially reduce the chance of medical-legal difficulties.
The referral-consultation process requires an ongoing balance of shared care and responsibility between the referring and consulting physicians that may evolve as the patient’s care progresses. Clear articulation of the expectations on both sides is critical to maintaining that balance.

4. Expectations of referring physicians

These expectations apply to any physician making a referral including a primary care provider, specialist, and episodic care provider (e.g. physician at a walk-in clinic, emergency department, or a hospitalist). If the referring physician is not the primary care provider, the referring physician is also expected to communicate details of the referral to the primary care provider.

Prior to requesting a consultation, referring physicians should ensure the patient is aware of the purpose of the referral, and that the patient has agreed to the referral.

Referring physicians should:

a) only refer a patient to a consulting physician if indicated;
b) only refer a patient to one consulting physician at a time within a discipline for a specific problem;
c) act on a patient request for referral for a second opinion when the referring physician considers it to be a reasonable request;
d) provide a legible consultation request in writing unless circumstances prevent. The consultation request should be sent on a timely basis and should include:

the patient’s identifying information (including name, personal health number, date of birth, preferred and current contact details);
the referring physician’s contact information;
the primary care provider’s contact information, if not the referring physician;
date of referral;
specific purpose of the referral;
confirmation that the patient is aware of the referral and advice about any specific concerns expressed by the patient;
expectations of the consultation outcome (e.g. medical opinion only, treatment, transfer of care, shared care, etc.);
level of perceived urgency of the referral supported by available clinical information;
relevant clinical information (e.g. current medications, allergies, health history, physical examination) and social information (e.g. language barriers, gender identity) including other factors that may influence logistics and booking;
summary of patient’s current status (e.g. stable, worsening or urgent/emergent; symptom onset/duration; key symptoms and findings/any red flags);
copies or summaries of pertinent laboratory investigations, imaging and reports from other consulting physicians, highlighting the clinically relevant findings;
advice about any investigations that have been ordered and are pending;
current and past management of the issue including previous or concurrent consultations;
comorbidities including pertinent concurrent medical problems (and list other physicians involved in care if long-term conditions);

e) inform the consulting physician if there are clinically relevant changes in the patient’s condition or treatment or if there is a change to the patient’s contact information after the referral has been sent but prior to the patient being seen by the consulting physician;
f) continue to provide appropriate care to the patient for the referred problem pending the consultation.

5. Expectations of consulting physicians

Consulting physicians should ensure they have an appropriate system in place to triage and prioritize patients according to the assessed level of urgency of their condition. The system should ensure prioritization is done in a consistent and non-arbitrary manner.

Once a consultation request is received, consulting physicians should:

a) provide a prompt response to the referring practitioner and, if appropriate, to the patient/patient’s legal guardian within 14 days advising that the referral has been accepted or declined and advising of the anticipated wait time or appointment date. In the event of urgent/emergent referral, this communication should be appropriately expedited depending on the clinical scenario. To view an example of a letter confirming receipt of a referral in the context of a longer waiting period, see Appendix C. To view an example of an appropriate referral response letter if an appointment date has been assigned, see Appendix D.
b) once known, confirm the actual appointment date with the patient;
c) provide reasons if the request for consultation is declined, and whenever possible, provide suggestions to the referring practitioner for alternative consultants or services;
d) schedule the appointment directly with the patient except in exceptional circumstances;
e) advise the patient of any specific requirement prior to the appointment;
f) advise the patient to contact the referring practitioner if there is any change in their condition;
g) communicate to the patient expectations about office procedures and policies (e.g. cancellations or confirming appointments in advance).

After seeing the patient, the consulting physician should:

a) within 14 days of the attendance, provide the referring practitioner (and primary care provider if not the referring practitioner) a legible written report that includes:

the patient’s identifying information (including name, personal health number, date of birth, preferred and current contact details);
the referring practitioner’s contact information and the contact information of the primary care provider if they are different;
the consulting physician’s contact information;
the date patient was seen;
the purpose of the referral as understood by the consulting physician;
information considered, including relevant history, examination findings and investigations;
conclusions regarding diagnosis (definitive/provisional or differential diagnosis where appropriate) and explanation of underlying reasons for conclusions;
management plan, including goals and options for treatment and management:
- the appropriate investigations/diagnostics, with clear articulation of responsibility for ordering and following up the results;
- the treatments initiated, including medications either suggested and/or prescribed;
follow-up arrangements specifying the designated responsibility:
- recommendations for follow-up by the referring practitioner;
- recommendations for continuing care by the consulting physician;
- recommendations for referral to other consultants with a clear statement as to who will take the lead on this;
the advice given to the patient including with respect to any follow-up plans.

b) immediately contact the referring practitioner to advise of the outcomes of the patient encounter if the consulting physician cannot provide a written report within 14 days of the attendance;
c) ensure the patient has received all relevant information particularly with respect to follow-up arrangements;
d) provide the referring practitioner a follow-up report conveying the relevant information after subsequent visits with the patient where there has been any significant change in management or prognosis or the interpretation of results;
e) continue to see the patient in follow-up for the same condition within a timeframe that would be deemed reasonable by physicians in the same specialty. If the patient has a new concern or requires follow-up outside of that reasonable timeframe, the patient would typically require a new referral;
f) if appropriate follow-up requires further diagnostics, the timing and nature of those diagnostics must be clearly articulated. The expectation is that the most appropriate member of the care team, be that the consulting or referring practitioner, will order and follow-up on the results.

A consulting physician must explain to the patient the consulting physician’s role, if any, in the continuing care of the patient and the advisability of follow-up care by the consulting physician.

Both the patient and referring practitioner should be notified when a consultation is complete and patient care is being transferred back to the referring practitioner or primary care provider.

6. Diagnostic Testing

Unless otherwise mutually agreed between the referring physician and the consulting physician, the ordering physician is responsible for the follow-up of diagnostic testing (including pathology specimens). If the ordering physician has made arrangements for another practitioner to take responsibility for follow-up, those arrangements should be documented.

No physician should ever order diagnostic testing under another practitioner’s name, except in the situation where medical learners order tests under the name of their supervising physician.