Referral-Consultation Process guideline: an obligation to engage collaboratively for patients

The preamble in the Referral-Consultation Process guideline includes the following:

The College recognizes that there is a high degree of variability across the province in how referring physicians and consulting physicians engage in the referral-consultation process….

While there is no single solution to address all of the communication challenges, physicians should be mindful that patient well-being is the single most important factor in ensuring an effective referral-consultation process. In all instances, patients and their families remain at the centre of the referral-consultation process, and physicians should show their willingness to work together courteously and respectfully to ensure patient care is not compromised. Keeping the patient informed throughout the referral process is of the utmost importance.

Some have interpreted the guideline as a means of addressing a perceived fairness issue by shifting a resource-intense activity (communicating with patients) from referring physicians to consultants. But the College has no jurisdiction over issues directly related to the business side of practice.

The guideline articulates the proper role of the College by borrowing from the CMPA Good Practices Guide:

Good communication and collaboration between referring physicians and consulting physicians can prevent disruptions in care, delayed diagnoses, unnecessary testing, avoidable complications, frustrated physicians and patients, and potential medical-legal difficulties.

Accordingly, the guideline states that referring physicians should continue to follow the patient and fulfill the most-responsible physician role (or ensure that someone else will) until the specialist sees the patient and that “in most situations, the consulting physician is best suited to communicate the appointment date and time to both the referring physician and the patient.”

It has been disappointing to see some registrants respond to a call for collaboration by sending terse fax messages to colleagues.

On several points of apparent confusion:

  • The College has been asked how the guideline will be enforced. Guidelines, by definition, are recommended, not mandated courses of action. They are not enforced in the abstract. In the event of a complaint alleging an adverse patient outcome, physicians who opt not to apply a guideline in individual circumstances may be held accountable.

  • As noted in the earlier College Connector article, some specialists have stated their intention to ignore the guideline and direct every request to contact patients back to referring physicians. The College views this as inadequate and unacceptable. The expectation to “work together collegially, and to share the responsibility of supporting patients” is obligatory. Specialists who cannot document an approach that fulfills the spirit of the guideline may be subject to criticism if a patient suffers an adverse outcome as a result.

  • Some referring physicians have adopted a practice of demanding specialist compliance to the letter of the guideline in every instance. This is unreasonable and, in some instances, unprofessional. There are often compelling reasons for following a different course. Examples include requests for urgent consultation and circumstances where specialists are coping with the abrupt loss of colleagues and must ration their services in the public interest.

As the guideline states, the College expects referring physicians and specialists to work in concert to ensure smooth transitions for patients. In many communities, Divisions of Family Practice are effectively using their resources to engage specialists and, where possible, accommodate individual circumstances. The College is advised that new technological solutions may soon facilitate effective referrals. The implementation of a guideline is meant to be a catalyst in support of innovation.

The College acknowledges that the majority of physicians are following optimal referral-consultation processes, and while the College sympathizes with those who find the transition challenging, it can only reiterate the expectation in the guideline that referring physicians and consultants take ownership of the issue and engage collectively to address it.