Physician referrals from a rural family practice residency clinic: a pilot study

Primary care physicians see large volumes of unscreened patients in the office setting, and referral to more specialized colleagues is always an option. Discretionary factors may play an important role in the referral decision. In this study, three family physicians retrospectively rated 410 referrals from a rural academic practice for the need for referral based on lack of specialized skills or knowledge by family physicians and the probability of adverse patient outcome. Referrals relating to cancer and pregnancy were rated as less discretionary than other referrals. Specialties receiving the highest proportion of mandatory or probably mandatory referrals were ophthalmology and cardiology. Half of all referrals studied were considered to be elective or possibly elective, although 97 percent of referrals to dermatology were considered elective or probably elective. These findings support the hypothesis that there is considerable clinical discretion in a large proportion of referrals. Hence, imposition of specific criteria for referral in primary care practice (thereby limiting discretion in initiating a referral) could significantly decrease the number of referrals, and consequently decrease the income of subspecialists and tertiary care centers.