Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/icons/misc/sectionDOWN.gif)
missing links
- Robert C Kane, MD (30 March 2003)
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Referral protocols and variation in referral rates
- David Keene (4 April 2003)
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Litigiphobia
- Christopher B Forrest (16 April 2003)
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Gatekeeping from a patient's POV
- Clare M Ackroyd (23 May 2003)
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Robert C Kane, MD, private practice Venice, FL 34285
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It is impossible to describe or evaluate health care in the U.S. without assessing the influence of the lottery system known as malpractice. One of the best defenses is to "refer early and refer often" to borrow a phrase. To compare referral utilization against an alternate system where patients and the legal profession have different morals is comparing "apples and oranges." Competing interests: None declared |
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David Keene, GP Referrals Adviser City and Hackney PCT, London N1 5LZ
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General practices in City and Hackney,an inner city area of London, have up to ten fold variation in referral rates for all specialities. This tends to be constant for most specialities. In general, practices are proud of their gatekeeping role, yet apply it very differently. Even after allowing for individual practice characteristics there remains a large variation between practices that one can postulate is a function of the physician. This often leads to the charge by consultants that GPs make "inappropriate" referrals. This implies that they do not use their gatekeeping role responsibly, yet each would defend their referral decision. The issue seems to be linked to a lack of adequate responses to a clinical situation in primary care. Many GPs feel that consultant referral is the only model available, a view that may receive tacit agreement from consultants. I agree with the assertion by Forrest that electronic decision support carries great potential. In the UK this could be offered as a part of the development of electronic booking for out patients, a policy to which the NHS is committed. It will require the development of criteria to identify whether referral is required, and a range of alternative responses if patients do not meet the criteria for referral. This has the potential to support and enhance the general practitioners gatekeeping role, whilst retaining the integrity of the doctor patient relationship. It remains to be seen whether this opportunity is used to understand and influence the wide variation in GP referral rates. Competing interests: None declared |
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Christopher B Forrest, Associate Professor 624 N. Broadway, Rm 689, Johns Hopkins University, Baltimore, MD 21205 USA
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The impact of physicians' fear of malpractice on referral rates has been studied in the US. Our group has examined thousands of referrals made by primary care physicians and the reasons for making those referrals. Concern about malpractice or "medico-legal" reasons was cited as a reason for referral in no more than 1 in 100 instances. In most cases when litigiphobia may have been operative, physicians reported other reasons for making the referral. Other studies have similarly found a negligible impact of defensive medicine on variation in physicians' referral rates. I believe the evidence is best for the following factors as the main determinants of referral decisions: prevalence of the presenting problems, the overall complexity of the patient, physicians' scope-of-practice, tolerance of clinical uncertainty, and availability of specialists in the community. Competing interests: None declared |
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Clare M Ackroyd, patient n/a
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Over 59 years as a health consumer, I've experienced a multitude of gatekeeping types, some excellent, some not so excellent. The best was an HMO, where even the Nurse Practitioners were excellent as gatekeepers, taking the needs of the patient in mind. However, the worst two experiences I have had were getting young women on the phone who probably had high school diplomas, who didn't even understand (or know how to spell) the condition I was talking about. I had had to make the request for referral myself in these health organizations. In one or both of these situations I was turned down. In both, I appealed and finally spoke to an MD. In the case of wanting a second opinion for a cholecystectomy, I won my appeal. I frankly don't remember the outcome of the second. Gatekeepers should be medical personnel, either advance practice RN's or MD's, no less! Competing interests: None declared |
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