Trevor’s Take On: Professional Etiquette & Referral Consultation

College of Physicians and Surgeons of Alberta Messenger, Trevor's Take On 10 Comments

Merriam-Webster defines etiquette as “the rules indicating the proper and polite way to behave”. Others define it as “the customary code of polite behavior in society or among members of a particular profession or group”.

So what is professional etiquette when it comes to the referral-consultation process? As in many parts of life, the Golden Rule offers good advice: How would I want to be treated if I was the other physician?

Most importantly, how would I want to be treated as the patient? Surely the answer from all sides is with a level of consideration that ensures the best, most timely care.

At its meeting this September, Council considered feedback from the profession and others, and approved amendments to the Referral Consultation standard of practice. The amended standard clearly sets out expectations that define professional etiquette in how this process is managed.

One might think, perhaps, that doing so would be unnecessary. But, clearly, it is necessary. Too often we receive emails, calls and complaints about the behaviour of physicians on both sides of the referral-consultation equation.

For referring physicians, we hear concerns that:

  • The information provided is insufficient (“please see and treat”, with no supporting information or documentation) and no attempt has been made to establish a diagnosis or even consider a diagnosis.
  • The patient has not been properly examined (“please see re: cauda equina syndrome” when no rectal exam has been done/documented, for example).
  • No clarity has been provided as to the goal of the requested consultation.

For consulting physicians, the list includes:

  • Difficult access, manifest in a number of ways:
    • refusal to see certain conditions within the scope of that specialty
    • inaccessible processes for referring physicians (e.g., the office will accept new referrals only during one hour every fourth Monday)
    • requirements for specific investigations to be completed (e.g., the patient must have an MRI of the XX body part before a consultation will be considered)
    • delays in responding to the request for referral
  • Failure to provide the consultation report in a reasonable time.
  • Off-loading work onto the referring physician’s staff, the most common example of which is expecting the referring physician’s office to notify the patient of the time and date of the consultation.

If you see yourself or your practice in these bullets, then it may be time to look at how you run your practice or to ask colleagues who refer to you what you could do better.

In addition, I suggest you review the amended Referral Consultation standard of practice. While it has only a few changes, a couple are significant:

  • The consultant must make information available to referring healthcare providers about the process for receiving requests for consultation (i.e., how to refer to you should be easily found and understood by referring healthcare providers), and
  • The consultant must acknowledge receipt of a request for consultation to the referring healthcare provider within seven (7) days, and communicate to the referring provider the decision to accept or deny the request for consultation within a time commensurate with the urgency of the request but not longer than fourteen (14) days after the request was received. These timelines have been shortened, consistent with the recommendations of the Health Quality Council of Alberta in its Continuity of Care report.
  • While not a change, this bears repeating: The responsibility to contact the patient as to the date and time – and any unique details – of the consultation remains with the consultant.

In my view, this all comes down to simple etiquette.

Your feedback and comments are always welcome.

Trevor Theman

10 Comments on Trevor’s Take On: Professional Etiquette & Referral Consultation

Michael Coe said : Subscribe Nov 18, 2016 at 6:14 PM

"Trevor's Take" on etiquette is right in identifying that it is a lack of etiquette on both sides of the discussion that has perpetuated this irritant. Trevor Theman's and Michael Caffaro's efforts are commendable on this topic of referral consultations. Ploughing through the voluminous feedback reveals a lot of thoughtful input and good ideas from out there - so I would like to think that the amended Standard soon to be in effect remains a work in progress with periodic reviews as to whether it is realizing its intentions of collegial harmony and patient benefit. I would like, for example, to see some reasonable flexibility on the issue of whose responsibility it is to apprise the patient of the appointment details. Surely the College should be able to live with different approaches to this aspect of the process. Ken Gardener said in conversation with me on a different topic that the College should not create a Standard when a spectrum of reasonable community standards exist (or words to that effect) - this seems to be a very wise approach! This consultation issue would have long found its working balance but for a regrettable deficiency of professional etiquette that is far too commonplace. 

    Daryl Jenken said : Subscribe Oct 16, 2016 at 10:42 AM

    With regards to "refusal to see certain conditions that fall within the scope of that specialty": There are precious few hours to practice most surgical specialties and and to see patients with relatively minor problems, instead of providing timely care to more serious problems (cancer) is not appropriate. To see patients you cannot help in the OR, although they may need it, is simply adding cost and delays them being referred to a practice that can provide them with surgical care.

      Noel Hershfield Clinical Professor(Hon.). said : Subscribe Sep 19, 2016 at 11:26 PM

      Lack of etiquette? It is lack of professionalism! To refuse to see a patient on the basis of a letter is simply unacceptable .To add insult to injury,to send back a letter with suggestions for management, is simply arrogant!A request for a consult is a cry for help. The College should unequivocally state that this practice is not professional. To remind you,your mandate is"We guide professional conduct and ethical behavior". How disappointing!

        John Fernandes said : Subscribe Sep 18, 2016 at 8:40 PM

        I am a Family Doc that also takes referrals from other Docs for office surgical procedures - and I see both sides of this issue daily. From the perspective of the Family Doc, many Specialists do not even acknowledge receipt of the referral until perhaps months later, if ever. This problem is particularly bad from the GI central Triage as well as the Rheumatology central triage in Calgary. Numerous other "Central Triage's" exist that follow what I consider to be similar poor conduct in terms of how they administer incoming referrals. All of this has been done to "increase efficiency" in the never-ending quest to "race to the bottom" - which has had these unintended consequences that such services are simply unable or unwilling to address (they have, in my opinion, achieved "the bottom"). I have lost count of how many of my very complete referrals have been responded to months later by a Nurse Practitioner who demands a whole host of unnecessary and inappropriate tests, as they follow some sort of "recipe book" to triage appointments for patients. These Nurse Practitioners actually state that the referral will not be accepted until "these tests are done and we receive the reports". It is good to see that the CPSA is determining such practices to be possibly unprofessional and at the very least discourteous. From the perspective of the receiving Physician on the referral side - it is huge amount of work that costs real time/expense to try to get ahold of patients with incorrect or incomplete demographics. We actually have to have staff tasked to such activities, which is another business cost. Without any history from a proper referral note, it is extremely challenging to triage such patients. There are also some days where we have seen 4 consecutive "no shows" because referring Docs send the same referral to at least 5 different consultants - but don't bother to cancel any of the unnecessary referrals. I totally understand that the referring Docs are just trying to work in the best interests of the patient, but it is very hard to have 4 no shows when I have a months-long wait list of patients desperate to be seen. This new policy from the College will do a lot to address both sides of the issue and is a welcome change that sets ground rules that are reasonable, and at the end of the day - the best thing for the patient. I am normally skeptical of the College's unwelcome intrusions into "real world" Medical Practice, but this latest amendment has caused me to reconsider my opinion. Well done, College!

          Robert Mulloy said : Subscribe Sep 19, 2016 at 5:55 PM

          John, Well said. "central triage" programs should be banned.

            Magnus Murphy said : Subscribe Sep 15, 2016 at 7:22 PM

            I already stated this comment when I responded to a request for comment earlier in the process... By this declaration, the College has almost ensured that accepting specialists who are in small, especially independent practices, will fail, and thereby has intentionally or otherwise, ensured that such will be in contravention of the edict from on high. Most offices are closed during holidays, often for more than a week. According to College rules, such physicians have to arrange for coverage for their patients, which is often done through colleagues in call-groups or on an individual basis. In cases as above however, this coverage does NOT include screening incoming referrals and it is completely ludicrous to expect that to be the case. Thus, is the College now proclaiming that it is unacceptable for a single physician office to close for vacation of the physician and staff for more than a week? That is in effect what this ruling is saying and I personally think it is poorly thought out, guaranteed to cause problems and failure to comply consistently. There is no provision in the ruling for this type of infrequent inability to comply - the ruling is therefore draconian and unacceptable. Talk about etiquette and respect. Well this does not suggest any respect in return.

              Brian McAlpine said : Subscribe Sep 15, 2016 at 3:31 PM

              Wow.. after all these years.. cracking down on 'other than the low hanging fruit'.., nice to see.. refreshing change. And what if consultants say .. too bad so sad.. the next step?

                David Cross said : Subscribe Sep 15, 2016 at 12:30 PM

                As a specialist who takes all responsibility for contacting the patient and following through with reminders prior to the appointment, I would add two concerns. Some referring offices send referrals to multiple physicians in the same specialty in an effort to get the earliest possible appointment for their patient. Far better would be either to call each office to determine which one is offering the earliest routine appointment or to request an urgent appointment if that is appropriate. It is very frustrating to go through the work of contacting the patient etc. only to discover that the patient has been seen elsewhere when the appointment comes due. The second concern is that supplied phone numbers for the patient are often inaccurate or out of date, necessitating further work by office staff to obtain current information. My plea would be that referring offices make every effort to maintain the accuracy of their patient database and also supply all available phone numbers when making a referral.

                  Scott Allan Lang said : Subscribe Sep 15, 2016 at 11:40 AM

                  Thank you for your comments. I agree that if only people applied "The Golden Rule" it would be much easier to imagine what should be done. The challenge comes in operationalizing the ideal. That is, I suspect, where negotiation and communication will be most important. For example, if a consultant meets the expected time-lines and refuses to see a patient in consultation without suggesting alternatives or providing an explanation how will that impact patient care and is that professionally justifiable - does it constitute abandoning the patient or is it just bad etiquette?

                    Jeremy Reed said : Subscribe Sep 15, 2016 at 11:24 AM

                    Very well said Trevor. As a specialist myself, married to a GP/CASEM doc, our household sees both sides of it. It's amazing how the rule of "if you order it, you follow up on it" is, for the most pary, lost where we work. History and Physical is what we are paid to do in the office, and once those are done sharing that with your colleagues takes all of 30seconds and a dictaphone (note - transcriptionists should be typing, doctors should be seeing patients). Many things could be made better if all remained to committed to these basic skills. Wait times to see specialists, MRI wait times, ultrasound wait times, cost associated with unnecessary bloodwork - the list goes on. Sadly, even in the day of EMR's, simple legibility of handwriting sometimes is a problem. I hope your message gets some traction and all MD's ensure that the correspondence that leaves their office is something they are proud of, and can defend if needed. -J.

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