Superman may be great at pretty much everything but the other heroes use their own particular skills for a reason. When it comes to medicine there are issues that even general practitioners can’t handle, so when the time comes they will refer you to a specialist. Once we break down how referrals work you will improve your follow-up care with simple insights.
When any given doctor sends you to another provider, the primary intent to get medical opinions, surgical work done, or diagnostic help to support the best possible treatment for you. Picture a scenario where you’re in the exam room and your primary doc advises you to get a chest X-ray and visit a nearby plastic surgeon for something like a complex excision. This is where the hand-off in your care begins. A chord and line diagram made by the health tech company Amino shows the most common types of referrals. This retrospective study based on about 211 million referrals in 2016 shows that not every referral is a visit per se; a significant part of referrals from primary doctors like internists are directed to X-rays, EKGs, and mammograms. In essence, anything ordered for a diagnostic purpose is also considered a referral. When you open this graphic on my Substack post, which you’ll find at rushinagalla.substack.com, you’ll notice that internists, ER docs, and pediatricians are the common referring physicians, while radiologists, cardiologists, and dermatologists are part of the most popular rendering physicians. One thing patients get confused with is the slight difference between a consultation and a referral. The former concerns a doc-to-doc conversation for an opinion and the latter is a formal transition of care. For example, your internist might talk with a dermatologist about a rash you have to get insight on what treatment makes sense but you do not actually book with the dermatologist—that is a consultation. When you need to physically or virtually see the dermatologist yourself for the issue, that is a referral.
There’s one major concept I want to clear up for patients first: doctor referrals go beyond word-of-mouth because there are medical and legal elements that apply when getting in to see a specialist. A referral does not work like the sorting hat in Harry Potter that magically puts you where you need to be. As I’ve talked about in previous episodes, when you have an HMO or POS health plan you need to get a referral from your PCP to get coverage for a specialist. You don’t need to worry about this if you have a PPO or EPO plan, but you and the referring doctor would need to check if a specialist would be in-network to begin with. Regardless of the health plan, the actual transfer of care is a standard or coded document originating from the PCP and insurance, or a letter from doctor to doctor with all your necessary medical history attached. With all the info and extra steps, both parties assisting in your care will be able to 1) prove that your referral exists so you don’t get lost between offices and 2) legally bill your health plan. To be frank, referrals get so complicated that the average clinic has a separate manager or coordinator to handle them. Another factor to consider is that the wait time for a specialist like a cardiologist or dermatologist can take months. That’s why if you’re in a situation where you know that you need a particular specialist’s expertise, it’s a good idea to book earlier with your general physician to secure a referral in a timely manner. When the primary care office sends a referral, there’s probably a limit on time or number of appointments you can have with a specialist. Insurance companies usually mandate such a duration so medical fees don’t go overboard given that a specialist would charge way more than a general physician for a visit.
Thankfully we can leave the insurance and legal side of things alone for the rest of this episode and dig more into how you and your primary doc can make a great referral just like a clean baton pass on a running track. If you’ve never had a referral before, it’s best to trust your PCP’s medical judgement when it comes to picking the specialist. However, you should get the contact info for a specialist’s facility so you can research how their office works. Basically, trust the medical opinion from your doc, but verify that the office you’re being sent to is accessible. The two big red flags to watch for are if the PCP does not follow up with you to see if your referral went through and if the specialist’s office does not contact you within two or three days of getting the referral. To nip any problems in the bud, I suggest asking your PCP exactly what to expect for the referral in terms of urgency, visit expectations, and the content of what he or she is sending to the specialist. The American Academy of Family Physicians has an old but surprisingly applicable template of how the elements I mentioned fit together. The article will be in the post on my Substack page again found at rushinagalla.substack.com. Some physicians are going to be very hands-on. The proactive general doctor will call the specialist’s or lab’s office to speak with the rendering physician and provide other information about you that may be hard to define in an electronic medical record. Think of this like how a pro football scouting report gives you nitty gritty details on the opposing quarterback but a human coach walking through game film of the quarterback in action gives you even more insight. If your doctor cares and advocates for you this much, hold them a little tighter than a winning lottery ticket. The opposite end of the spectrum is the doctor delegating the majority of referral responsibility to you. Here your PCP sends a referral letter to another office but may give you prescriptions, labs, or any necessary written chart notes to hand off to the specialist when you go in.
The content of a specialist visit will be more focused than a traditional checkup. There are specialists who do take a holistic approach to their care but in most cases, they will address only your immediate medical priorities and PCP’s main concerns. Regardless of format, make the most of the time you have, continue to ask important questions like with a routine checkup, and get the written visit summary, assessment, or treatment plan after everything is done. You can also check if the specialist will send notes and correspondence back to your PCP. Your general doctor should also make clear with the specialist whether you are going to be immediately released back under the primary care office’s wing or if you need to continue following up with the specialist. Naturally this is going to vary with your current medical situation. In any case, we’ve finally closed the loop for how a typical referral works! The bottom line is that a ensuring a successful hand-off of medical care happens when you get transparency and clear expectations. When the time comes for you to get referred to specialists or labs, ask your PCP what their office’s exact referral process is, and get the contact info for where you are being sent to.
Before we finish up, there’s one question that might have popped up in your mind: what if I’m a little nervous or too scared to ask my specialist any questions or advocate for myself? This “whitecoat syndrome” is actually a real thing and there are plenty of patients out there who fear going to a clinic, but coming up next, we’ll talk about ways to deal with that anxiety and have an easier time face-to-face your doctors no matter where you go. Stay tuned and subscribe to Friendly Neighborhood Patient for even more medical system tips and tricks. I’ll catch you at the next episode.
