COMMENTARY

Standardizing the Referral Process: Yay or Nay?

Seth Bilazarian, MD

Disclosures

December 26, 2014

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This Seth Bilazarian, from theheart.org on Medscape. I wanted to bring to your attention an article in JAMA titled "Selecting a Specialist," from authors at the Brigham and Women's Hospital and the University of Toronto.[1] I should have anticipated that this was coming. We are in an era of medical and healthcare delivery that focuses on transparency, homogenization, and trying to create metrics for everything.

I would commend the article; it is well written, although there are some things that I disagree with. The concept of the article is creating quality metrics for referral to a specialist. Referring patients to other physicians is described as something that happens with great variability. I see this in my own practice. As a cardiologist, I receive referrals from primary care providers who are very uncomfortable with cardiology topics. Some of these patients, with abnormal ECGs, heart murmurs, or lightheadedness, probably don't need to be referred. On the other hand, sometimes patients with advanced heart failure are not referred but should be. Variability in referral is real and is an issue that perhaps does need some type of metric.

Factors that influence the selection of consultants are covered in great detail, and a box is provided that outlines the factors that demonstrate the consultant's clinical expertise. One item listed that does not resonate with me is the physician's published research on a topic. That does not resonate with me as a referral consideration, but for some it may. Interactions between the patient and the consultant, and interactions between the referring physician and the consultant, are all very well outlined.

My point is for practicing physicians, who are both making and receiving referrals, to think about this. I always think about the cliché that practitioners do well when they are "affable, available, and able." As a recipient of referrals, I sometimes think that perhaps I fall a little short on affability. I may be too stern with patients on preventive strategies. I am very tough with them on smoking cessation and those kinds of things. Availability means being available for appointments and being on time. Ability is difficult to measure in one's self but is an ongoing process.

Then I thought about the physicians to whom I refer patients, the main subspecialties being cardiac surgeons, structural heart disease experts, and electrophysiologists. I thought about how I would be troubled by qualitative metrics for physician referral and how that might, in fact, confuse and undermine what I think is a critical and important—and even a sacred—responsibility that I have toward patients to make sure that they are sent to the right physician.

In terms of the referral to a cardiac surgeon, for instance, my considerations are: Does the physician do a good job with delivery of care prior to the procedure, during the procedure, and after the procedure? Would the patient be pleased with the total experience at the institution? That is part of the referral process that I take very seriously.

From a structural heart disease standpoint, with the imaging requirements, patients are traveling great distances to academic medical centers for these appointments. Does the center bundle appointments for the CT scans and echocardiography and other tests, or do patients have to go back and forth repeatedly, making it more difficult for patients to get excellent care?

How would these metrics be used for electrophysiology referrals? I think of electrophysiology as being divided into three main subspecialties: atrial fibrillation ablation, device work, and cognitive arrhythmia management. Wouldn't it be more valuable to explain to a patient why I am referring to a specific physician for that patient, rather than relying on metrics about length of stay or outcomes of procedures?

We have come a long way from the Norman Rockwell Doctor and Doll of [1929], when affability was the main measure of a physician's quality. In that well-known Rockwell painting, a physician is examining a young girl's doll as a way to allay her fears. Obviously, this continues to be a critical part of the delivery of care for patients, and their expectations are that they will have confidence in us and have their questions answered in a timely and careful way. But beyond that, there are many other subjective things that are very important and that are almost impossible, in my mind, to objectify. Strategies like this could serve more to undermine care than to improve care.

I am interested in other physicians' perspectives, whether you are a referral or a referring physician. Is there utility in assessing the quantity and quality of referrals, and can we improve the transparency of this process? I have no answers on this topic but worry about computerizing what I think is our subjective and critical role as specialists. Until next time, I am Seth Bilazarian.

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