Serial analysis of referral letters – reasons for referral
This section may be used by a doctor to examine and reflect on the reasons that referrals are made. There are many factors that influence a doctor’s request for a second opinion not strictly related to clinical need. The reflective process may help you to identify areas that influence you and may throw up learning needs.
Using this template link complete as fully as possible for the next ten referrals you make (you could either concentrate on one specialty that makes you feel “uncomfortable” or you can just analyse your next ten referrals). You may wish to include your reflections on the issues identified and learning points on MARS, and include your analysis as additional supporting documentation.
| Short clinical details | Reason for referral including what you expect to achieve by referring | Any non clinical factors? | Could anything be done differently? |
|---|---|---|---|
| 67 year old man with inguinal hernia | Consideration of operative intervention | None really fit and healthy with new presentation of hernia | No |
| 28 year old with mild depression not responding to 6 weeks of fluoxetine | Consultation and support possibly from CPN | Attended with mother “something must be done” probably would have simply changed anti-depressant otherwise | Could have switched anti depressant could have used MIND who provide support |
| 57 year old man with shortness of breath on exercise no chest pain long term smoker normal ecg and cxr | Opinion of chest physician re probable COPD – and suggestions for further treatment | Patient concern wanted early referral – even before I had arranged spirometry | Could have further investigated with spirometry |
| 4 year old with eczema – not responding to emollients | Paediatric specialist nurse involvement to allay parental worries re use of steroids | Mother very reluctant to use even small quantities of low dose steroid | Difficult consultation mother really not interested in using steroids could have used tacrolimus but I really do not have the experience with this drug |
| 86 year old with history of stroke – residual weakness (mild) r leg – preventative treatment already optimised | Stroke prevention clinic to access Doppler and CT head | No direct access to interventions – interesting issues of when someone is “too old” to investigate | Discussed option with patient and daughter – optimal prevention is she really fit for end arterectomy ? |
| 72 year old with cataracts | Cataract surgery | None | no |
| 7 year old girl with recurrent tonsillitis | ENT opinion on need for surgery | Mother keen for surgery – has had 3 episodes of quite severe tonsillitis in last 18 months – I am unsure as to the guidance for tonsilar surgery | 3 episodes in 18 months does not seem all that much family expectations were high – watchful waiting was an option |
| 45 year old with breast lump | Rapid access breast clinic | Necessary referral but obviously very worried patient – seen within 2 weeks – benign changes only | No |
| 76 year old man asthma life long now with mixed asthma COPD picture requesting nebuliser as it had helped greatly in hospital recently | Nebuliser assessment | We have a nurse led clinic for nebuliser assessment – this is a useful resource | No |
| 74 year old man longstanding OA knee – had injections in past now not responding to injection / NSAID | Knee replacement | Issues here with waiting times – is to get initial consultation privately but cannot afford private op | Have been considering trying Hyalgan – see cross reference under prescribing new drugs |
Are there any issues you would like to record about the referrals above?
By recording my thoughts at referral I was quite surprised that a number of these referrals were generated mainly through pressure from patients or relatives. These 10 referrals were generated in a 3 week period during which time I had consulted with 162 patients. Overall my referral rates within my practice are comparable to my partners. The nurse run clinic for nebuliser assessment is a good resource and we have similar clinics for insulin conversion, Sigmoidoscopy and paediatric dermatology.
Are there any learning points?
I need to examine the guidelines for tonsilar surgery to be able to advise other patients appropriately. I wonder if I need to be a little more assertive in dealing with patients who are only partially investigated for example the patient whom I referred without performing spirometry (this may also point toward my poor knowledge regarding interpretation of spirometry), and patient who are only partially treated – the young child with eczema and the issue of prescribing tacrolimus.