About Improper Performance

Referrals — Failure to refer, failure to track referrals, and failure to communicate with referring physician

While it is true that patients have a duty to comply with their physicians’ recommendations, including following through with referrals, it is common for them to claim that the physician did not stress the importance or did not explain the reason for the referral. In fact, they sometimes claim that they were given an option, as opposed to a recommendation, to see a consultant.

Implementing a system to track referrals can improve patient care and reduce liability exposure. The system can provide a method for:

• verifying that the patient keeps the appointment;
• confirming receipt of the consultant report;
• prompting a call to the consultant if a report is not received;
• making sure the physician sees the report; and
• arranging for a follow-up appointment if necessary.

If the patient fails to keep the appointment with the specialist, the staff can then remind the patient of the importance of following through with that recommendation. These steps should be documented in the patient’s chart.

As with reports of test results, written procedures for handling consultant reports can prevent problems and improve patient compliance. Initialing and dating reports or electronically signing them after careful review can provide useful documentation if a lawsuit is filed.

Another issue involves communication between physicians. While written communication will often suffice, there are some situations in which a discussion needs to take place. It is also important to document your discussions with other physicians and any joint treatment plans resulting from the referral.

‍Consults and referrals in the hospital

Ensuring that appropriate consultations are obtained and applied to a patient’s care is an important duty for hospitalists. Consulting medical specialists also have a duty to ensure hospitalists receive the information they need. Consider the following guidelines from the Society of Hospital Medicine. (1)

1. Determine why you have been asked to consult. What question is the ordering physician attempting to answer?
2. Establish the urgency of the consultation. Is it an emergency, urgent, or routine? The answer will determine how immediate your response should be, but all consults should be seen within 24 hours.
3. Gather primary data. Do not rely too heavily on what is in the patient record. “Obtain your own history and physical — your expertise may allow you to extract overlooked information.” (1)
4. Communicate as briefly and concisely as appropriate. Don’t allow your findings and recommendations to be lost in a barrage of too much information. The ordering physician may be inundated with reports and other consult recommendations to parse through your report to discover your findings. “Consults are more effective when they are brief (five or fewer recommendations), are detailed, and provide contingency plans.” (1)
5. Make specific recommendations. Studies have shown that the more specific the recommendation, the more likely it will be followed by the ordering physician and the patient. (1)
6. Provide contingency plans. Anticipating problems and providing recommendations if those problems arise can save valuable time for you, your colleagues, and the patient. (1)
7. Understand your own role, as a consultant, in the process.
8. Offer educational information, as appropriate, to the patient, requesting physician, and the other health care professionals seeing the patient.
9. Communicate recommendations directly to the requesting physician. Do so verbally, to foster a more effective consulting relationship and find agreement on a plan of action. If you do not agree with the plan taken by the requesting physician, discuss your concerns at this time. Do not simply document your concerns in the patient records. (1)
10. Provide appropriate follow-up.

Failing to listen, communicate, and spend adequate time with patients

Research on why patients sue physicians has repeatedly shown that basic interpersonal skills such as listening and showing respect can be just as important as clinical skills in preventing lawsuits. (2)

Eye contact and attentive listening are important and can go a long way in building a relationship with the patient. And patients who have a good relationship with their physicians will be less likely to sue if a bad outcome occurs.

Another key factor involves the quality of time spent with the physician, not just the quantity. Short visits can be effective if you sit down, listen to the patient, ask the appropriate questions, and allow patients time to ask questions. If you spend the entire visit with your hand on the doorknob, patients may feel rushed and may not give you complete information.

If you’re asking, “How can I improve a patient’s perception of a satisfactory visit when time is limited?” here are some tips.  

• When possible, schedule the length of the appointment based on patient needs.
• During the appointment, spend time connecting with patients on a personal level.
• Before patients are taken to the exam room, it may be helpful to ask them to complete a form that prompts them to state the reason for their visit.

Sources

1. Chang D. MD, FHM; Gabriel E. MD. 10 Tips for Hospitalists to Achieve an Effective Medical Consult. The Hospitalist. July 2015. Available at https://www.the-hospitalist.org/hospitalist/article/122225/10-tips-hospitalists-achieve-effective-medical-consult/3/. Accessed December 4, 2024.

2. Mostafapour M, Fortier JH, Garber G. Exploring the dynamics of physician-patient relationships: Factors affecting patient satisfaction and complaints. Journal of Healthcare Risk Management. May 5, 2024. Available at https://onlinelibrary.wiley.com/doi/10.1002/jhrm.21567 . Accessed December 4, 2024.

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