Reverse consultations: the profiles of patients referred from subspecialists to generalists

To determine the characteristics of patients referred by subspecialists to generalists, we compared 67 patients referred by three medical subspecialty clinics to the general internal medicine clinic to 162 randomly chosen patients who were retained by those clinics, with respect to the patients' need for a broad array of services. A trained abstractor reviewed the records for the prior year for patient characteristics indicating a need for broad-based care. The mean referred patient age was 53.7 yr compared to 46.2 yr in the retained group (p = 0.001); 33% of referred patients, as compared to 20% of those retained, had references to psychosocial problems in the physician notes (p = 0.03). Referred patients had 2.34 diagnoses outside of the subspecialty, compared to 1.27 for retained patients (p = 0.001). Referred patients had more recorded complaints outside of the subspecialty, 1.18 vs 0.71, (p = 0.02). Referred patients also had significantly more total clinic visits and visited twice as many different types of clinics in the past year (p = 0.001). There were no differences in payment method or insurance status. These findings suggest that university based subspecialists prefer to refer medically and psychosocially complex patients. If it is desirable that subspecialists value such patients more highly, changes in subspecialty training programs might be needed. If not, more generalists may be needed to care for such patients.