This is an excerpt from An Acupuncturist’s Guide to Medical Red Flags & Referrals by Dr. David Anzaldua. This book is an essential reference for any acupuncture clinic. For more information about this book, go to this link. This is one of my favorite chapters from this book and the book, as an essential reference text, could save someone's life (not to mention your career).

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CHAPTER 2: CONSULTATION AND REFERRALS

The ability to identify red flags is a crucial skill. So is the ability to effectively and efficiently consult other health care providers about the serious conditions they may signal. The consultant you choose is up to you. It doesn’t necessarily have to be a medical doctor, but it does need to be someone who can competently determine if the condition you are concerned about is present or not. There may be time when you think your optimal consultant might be an acupuncture colleague with a particular skill set just right for your patient or a naturopath, for example. The material in this chapter applies regardless of who you consult.

Often enough, however, due to the conditions we cover herein, and because we are talking about consultations in the U.S., the consultation will be to a modern scientific medicine (MSM) practitioner, a medical doctor. Unfortunately, consultation skills are generally poorly covered in many acupuncture or medical schools.  Students and practitioners are often left to learn this skill on their own, leaving a lot of room for mistakes. This chapter is designed to give you the preparedness you need to effectively and even enjoyably consult other practitioners. You may want to read through it quickly and refer back to it at the time of actual consultation later.

This chapter will cover several levels of consultations and referrals.

1.     911 type referrals.

2.     Sending a patient to a hospital emergency room or department (ER or ED) of a hospital.

3.     Consultations on a semi-urgent basis (within the same day to several days).

4.     Consultations in a timely manner (within several days to 2 weeks).

The first two, though dramatic, will be covered only briefly because, despite the seriousness of the situation, the level of effort and finesse on the part of the acupuncturist is minimal compared with consultations that involve semi-urgent or timely consultations and referrals.

911 and ER referrals

Let’s say you have an urgent situation that develops in your clinic. A patient is on the table getting acupuncture and begins having severe shortness of breath, for example. In the cases of emergencies that require activation of the medical emergency response system, you call 911. When the emergency responders arrive, they’ll want to know your concerns regarding the patient, which they’ll forward to the ED staff in a hospital.

Below is a streamlined guide for how to handle 911 emergencies, a summary, not a substitute, for guidance provided in standard Basic Life Support/First Aid manuals as published by the American Red Cross.

1.     Call for help and dial or have someone in your office dial 911 to activate the emergency services system.

2.     Provide CPR, basic life support, and first aid if needed until emergency services personnel arrive.

3.     Maintain communication with the 911 operator and ensure that the patient and the office environment are prepared for immediate patient transport upon arrival of emergency services personnel.

4.     You will be asked some basic questions about the patient’s situation by the medical response team that comes to your office. These concerns will be forwarded to the waiting ED staff.

5.     You should meet the patient at the ED if your treatment caused the harm, e.g. pneumothorax.

Sending a patient to an ER without a 911 call (with a family member driving the patient, for example) takes a little more finesse. This is because you will ideally call the ED before the patient arrives there to give the triage nurse or attending physician (they will tell you who will receive the call) a “heads up” about your patient before he or she arrives.

Neither emergency referral scenario listed above, however, requires the kind of communication skills of timely and semi-urgent consultations, the subject matter for the rest of this chapter.

Timely and semi-urgent consultations

Consultation regarding patients who need to be seen in a timely or semi-urgent basis will require more sophisticated skills than referring emergency patients. In these cases, you will be consulting practitioners you may develop collegial and even cordial relationships with over the years. The difference between uncomfortable and ineffective versus mutually rewarding and beneficial consultation is often primarily determined by the attitude and degree of preparedness of the referring practitioner. This chapter shows you how to do it well.

Consultation and referrals

First, let’s define what we mean by “referring” and “consulting”. Basically, consulting a practitioner is the same as referring the patient, but the words “consultation” and ‘referral” have somewhat different connotations worth exploring. I prefer to say that we are “consulting regarding a patient,” rather than “referring the patient” because “consultation” connotes a sense of collegiality and ongoing conversation between equals, whereas “referring” can imply that we are sending a patient to be “taken over” by a consultant because we “can’t handle it.”

The latter is certainly not the case, which should be obvious by the tone of this chapter. If we remove this negative connotation to the word “referral,” we can use the words “consultation” and “referral” interchangeably. Whatever we call it, the consultation is a request for specific services you wish to have rendered to your patient. The referral can be accomplished in a way that is beneficial for you, your patient, and your consultant. The more specific the information is about the patient that and more specific you are about what you want the consultant to do for the patient, the better.

It is your prerogative to set up the parameters of the consultation relationship with your consultant to accomplish your intended goals (see step 2 below on determining what services you want for your patient).

6 steps to successful referral of timely and semi-urgent patients

After you have spotted and thought about the red flag, the 6 steps you must take for semi-urgent referrals are the following.

Step 1 – Determine who you want your consultant to be

Step 2 – Determine what service(s) you want your consultant to perform and the role you intend to play in your patient’s ongoing and future care (see consultation form)

Step 3 – Prepare yourself with the right “mind set” for the referral

Step 4 – Organize your clinical data logically for presentation

Step 5 – Contact your consultant and Present your referral in a clear, concise, standardized way

Step 6 – Document your referral in the patient chart so you are in a strong medico-legal position in the event that the patient suffers a poor outcome regardless of your best efforts

Step 1 – Determine who you want your consultant to be

If you want to consult another specialized acupuncturist or alternative practitioner, you can go through the professional listings for these practitioners to find the ones you want if you do not already know them. In the case of medical doctors or institutions, you can choose from a variety of physicians listed in the phone book or online under the specialties (you should have this information ready ahead of time) if you do not already know your consultant.

Referring directly to a specialist, however, is probably not the optimal way to refer such patients. Rather, it’s best to refer a patient with a timely or semi-urgent condition back to their primary care provider (PCP) first, if one is available, rather than attempting to send the patient directly to a specialist. We’ll cover the reason why in a moment.

By PCPs, we mean doctors of medicine or osteopathy from 3 specific specialties: family practice, pediatrics and general internal medicine. Such physicians are considered “primary care specialists,” but it is also correct to refer to them as “primary care providers” – PCPs – because that’s the function they perform. (We use “PCP” for this group for sake of brevity while fully recognizing and respecting the fact that acupuncturists are also PCPs in some states).

7 important reasons to refer the patient to their PCP rather than directly to a specialist

1.     The PCP might be more accessible and is more likely to have a close relationship with the patient and more ready to “go the extra mile” than a specialist who doesn’t know the patient.

2.     The PCP probably has additional medical and family history that will be useful to all consultants who may eventually attend the patient.

3.     Many PCPs have contacts and knowledge of specialists within the consultant community that make further referral to the best specialist or institution more likely.

4.     Many patients are insured under managed care plans, which will require a referral from a PCP within the patient’s managed care network before they can access a specialist.

5.     Many specialists will only accept referrals directly from a PCP. Valuable time can be wasted trying to refer the patient to a specialist only to have the patient informed that a referral is required from their PCP for insurance or other reasons.

6.     When you refer to PCPs you begin to build a rapport with them that may well encourage them to send patients back to you – a practice-builder.

7.     Not referring a patient back to his or her PCP could be interpreted by the PCP as a sign that you do not understand the importance of the PCP relationship and/or importance of coordinated care.

For these reasons, our recommended default for non-emergency referrals (semi-urgent or timely referrals) is that they be made to the patient’s primary care physician, or to free-standing medical or urgent care clinic (not in a hospital) if no primary care physician is available.

In this later case, the physician in a free-standing medical or urgent care clinic temporarily plays the part of the PCP and can refer the patient further. Referral to a walk-in clinic may also be an option if a patient has an unsatisfactory relationship with their PCP or the condition you are concerned about has already been dismissed by the patient’s PCP – an unfortunate situation that does arise occasionally. Non-hospital walk-in clinics may become more available for patients without PCPs if health care reforms passed in 2010 are instituted so that semi-urgent situations can be seen in outpatient clinics rather than inappropriately in the ED.

There are a few circumstances, however, in which referral directly to a specialist may be an appropriate option.

1.     A patient’s PCP asks you to send the patient directly to a specialist.

2.     The patient’s current PCP is inaccessible, no free-standing clinic is available, and the case is urgent enough to warrant referral directly to a specialist.

3.     You are serving as the patient’s PCP (they have no medical PCP), you have an established referral relationship with a specialist whom you consider appropriate, and managed care insurance is no obstacle to a direct referral.

Care must be exercised with referrals directly to specialists for several additional reasons not covered above, however. Although specialists are excellent when looking at conditions within their area of expertise, they might miss something not within their domain that might be evident to a PCP with a more general medical background. Also, a patient will probably also eventually need a PCP, so even if referral is made directly to a specialist, the specialist may well advise the patient to obtain a PCP for complicating general medical problems like diabetes, hypertension, etc.

Step 2 – Determine what service(s) you want your consultant to perform for your patient and the role you intend to play in your patient’s future care

Your communication with your consultant should clearly state what service, from those listed below, you would like them to provide for your patient and how you will interact with them and your patient in the future (see sample consultation form and letter, appendix A).

1.     You are sending the patient for evaluation and suggestion of treatment options which you will then discuss with the patient to help them make treatment decisions.

2.     You are sending the patient for evaluation and co-treatment of the condition with you.

3.     You are sending the patient for evaluation and total treatment of the condition and will see the patient during the meantime for other problems and will continue to take care of the patient after treatment for the referred condition.

Step 3 – Prepare yourself with the right “mind set” for the referral

Communicating with other health care professions doesn’t come naturally to everyone, and may not seem as important as learning ancient medical secrets or modern medical science. When difficulties in referring patients are encountered, it’s also common to feel some anxiety, distress, and frustration. Additionally, acupuncturists accustomed to a slow-paced and informal style of communication may feel distressed by contemporary medicine’s demands that only the most pertinent information be transmitted in the minimum time necessary.

Common fears that some acupuncturists may feel when referring patients include:

1.      Anxiety that their concerns about the patient may be perceived as over-blown or their diagnostic impressions inaccurate.

2.     Fear that they may be perceived as having misled, mistreated, or even endangered the patient if a patient’s condition is revealed to be more serious than originally believed.

3.     Fear they may encounter veiled contempt for, or abrupt dismissal of, their form of medicine.

4.     Fear of loss of respect and status in the eyes of patients, peers, physicians or themselves when faced with the fact that a patient’s case seems to require further assessment and intervention beyond their own clinical practice.

5.     Fear of responsibility for the patient condition if the referral is not conducted effectively and the patient’s health is endangered by unnecessary medical procedures or therapies.

It may offer some small degree of comfort to know that these types of feelings are not unusual. In fact, they are even the rule among a variety of practitioners from many different healing systems, especially when starting out in clinical practice. Acknowledging them and using the antidote for them, as outlined below, will help guide you to effective consultations.

The antidote for fear of consulting – the proper mindset

The ultimate antidote for emotional turmoil regarding consultation and/or referral is to constantly remind ourselves of why we’re referring in the first place – out of concern for the well-being of our patient. All other considerations pale in comparison. If our focused intention is the patient’s health, and we remind ourselves that we must make our best effort at consultation because of patient needs, it is easier to face challenges we may encounter.

It is also important not to pre-judge how the process will go before it happens. Unless consultation has been attempted according to the helpful guidelines in this book, we cannot accurately estimate how future consultations will turn out by looking at the results of past attempts. All clinicians, in fact, stand an excellent chance for successful and collegial consultations if the methods in this text are used regardless of their healing tradition.

We should also remind ourselves that many patients actually need multiple approaches to health care. Many patients are actually cared for optimally by a team made up of family, friends and a number of health care providers that may vary throughout their lives. Patients may have strong preferences for one type of care or another, but it is the rare patient that will not need different approaches at different times. Our true role is as part of the health care team.

Step 4 – Organize your clinical data logically for presentation

If your telephone calls or letters of referral to your intended consultant are organized according to the accepted standard medical framework for referral, you will be pleasantly surprised by the positive response you’ll receive. Consultants can forgive a lot of things, including a neophyte status in the referring practitioner, but they don’t like a disorganized presentation that rambles and doesn’t give them the information they need to make decisions efficiently, any more than you would.

Don’t underestimate the importance of a standardized patient presentation when it comes to referrals. Referrals should be organized strictly by patient ID, history, physical exam, assessment, and plan. Referral is not the time to stray from this tried-and-true formula. Never get on the phone or write a letter to a consultant until you’ve first taken the time (usually minimal) to organize your data. Jotting down a few notes to keep you on track ahead of time will help this when you start out.

Step 5 – Contact your consultant and present the patient in a clear, concise, standardized way

When referring the patient to their PCO, it’s best to contact them directly by phone, fax, or secure e-mail. It’s second best to leave a phone message with the receptionist. If you leave a message for the receptionist it will only add a layer to the communication process and the receptionist may not have the training to recognize the semi-urgency of the situation.

It’s also advisable to provide the patient with the contact information for the physician’s office and encourage them to follow up directly with the physician if an appointment cannot be made while you are on the phone with the consultant’s office. Providing the patient with physician contact information is not a substitute for your direct communication with the physician’s office, however. If you simply hand the patient some business cards or a slip of paper with phone number and say “give them a call,” the patient may decide otherwise.

Remember that if the patient’s primary care physician doesn’t respond, that is a problem with their response system, not your referral efforts. The final section of this chapter deals with situations in which the consultation doesn’t go as smoothly as you would like.

The presentation, sample dialogue:

Hello. Is this doctor Jones? Thank you for taking my call. Yes, this is Richard Needles. I’m a local acupuncturist seeing your patient Henrietta Smith, date of birth 01-10-1980. I’d like to give you some important information about her. Do you remember her offhand, or do you want to get her chart before we talk?

This is it in a nutshell, Doctor Jones. History: Mrs. Smith came to see me for back pain today, but claimed she’s also had a swollen left ankle since returning from a trans-Atlantic fight last week.  Physical: Her left ankle is indeed swollen and measured 4 cm larger in diameter than her right ankle 5 cm above the medial malleolus. Assessment or Impression: I’m concerned about the possibility of a DVT in her left calf. Plan: I wonder if you’d have the opportunity to see her for this today.

The referral can turn in a number of different directions at this point, depending on what the PCP says. Perhaps her PCP is late on his way to catching a flight out of the country. Perhaps he thinks the patient needs to go directly to the ED or wants to see her in his office right away. In any case, you’ve fulfilled your obligation. You’ve made your best effort to contact the patient’s PCP, which is always the best first step for timely or semi-urgent referrals.

Step 6 – Document your referral in the patient’s chart so you are in a strong medico-legal position in the event that the patient suffers a poor outcome regardless of your best efforts

Whatever method you have implemented, it’s important to document what you’ve done in the patient’s medical record. One time-efficient method is to fax or mail a copy of your written referral (Appendix A) to the physician’s office and provide the patient with a photocopy with advice to follow up and also file a copy in the patient’s medical record. It also is advisable for someone on your staff to call the PCP’s office to ensure they have received the referral.

Delays are common in accessing physician care in settings other than same-day urgent care or emergency room facilities, which is another reason it’s advisable to initiate the referral the same day the condition is detected, preferably before the patient leaves your office. This is particularly true if you are referring the patient to a PCP who may need time to refer the patient to another series of specialists.

What do you do if, despite your best efforts, a referral “goes bad?”

By “going bad” I mean:

1.     The consultant seems poorly responsive to your referral, and you get little or no feedback from them regarding your patient’s case.

2.     The patient keeps an appointment but has personality or communication issues with the consultant or their office that preclude an effective rapport between them.

3.     The apparent seriousness of the medical problem does not seem to be adequately addressed or even recognized by the consultant.

With the exception of out-and-out rudeness, which is always inexcusable, we need to be careful before concluding that a consultation was unsuccessful due to lack of receptivity on the consultant’s part or a seeming lack of concern about the situation. Except in the case of a consultant not taking your call (you can always fax them or write a letter) there may be reasons for what seems like a less than enthusiastic response that has little, if anything, to do with you.

Assuming you present the consultation as discussed in this chapter, the consultant might be: in the middle of another case, fatigued from having been up all night in the ED the night before, or a number of other unforeseeable situations beyond you or your consultant’s control. It’s also possible that the patient presented a different history to the consultant than you obtained, misunderstood the consultant, or was misunderstood by the consultant. The patient’s condition may also have changed (hopefully better) between the time they saw you and the consultant.

Consultants should let you know about some of these occurrences by calling you or sending you a note, but it is always possible for you to call the consultant and ask for his or her opinion regarding the referral. Communication is a two-way street. Referring acupuncturists and consultants don’t always walk that street perfectly, but the effort is important on the patient’s behalf. Personality clashes are also possible. If they happen between your consultant and your patient, there is nothing you can do about it.

Let’s say, however, that your patient returns to you and, after careful thought, you conclude that their problem was not adequately addressed for whatever reason. There are still options. You must remember the primary principle: we are referring for the benefit of the patient and for no other reason. The patient’s needs must come first. What is the patient’s need in this situation? It is clear. The patient needs another referral for a more satisfactory consultation.

We have to be creative in this case. Why needlessly offend a consultant who might be needed for future consultation or someone who might have simply botched a particular referral?  Wisdom would have us keep beneficial relationships with everyone, if possible. What we have to do in this case is put the decision making power squarely back in the hands of the patient, where it belongs,  but also guide the patient to exercise that choice for another consultant.

Here’s an example dialogue that might do nicely in this situation in the case of a patient who did not have their own PCP to refer to and was sent directly to a specialist

YOU: I understand you didn’t feel that Doctor W. understood your problem.

PATIENT: He didn’t listen to me at all. He just rushed me in and out.

YOU: I wish there were something we could do the change that, but it’s out of our hands. My primary obligation remains to help you. Even though I don’t know exactly where the “disconnect” occurred with Dr. W., I’m still concerned about your symptoms.

PATIENT: You and me, both…What do you suggest?

YOU: I can’t tell you what to do. Ultimately, who you see is your decision. If I were in your shoes, however, I would seek a second opinion.

PATIENT: Who would you suggest?

YOU: I’ll give you a list of consultants. Since your situation is not an emergency, I suggest you check with your insurance to see which of these you might be able to see on your plan. Then give me a call back and I’ll send them a note to introduce you and your problem.