GP referrals are ridiculous — no wonder we’re burning out

There has been a lot of talk about specialist referrals lately.

It’s been suggested that the current state of many public hospital outpatient departments has led to GPs managing conditions that they might normally refer on to a non-GP specialist.

I can’t say I think this is a bad situation.

A competent GP can surely do quite a lot of the management that chronic conditions require — why else would we have item numbers supposed to support GPs to develop plans to manage chronic conditions?

But perhaps I don’t know what I don’t know.

As a country GP, I was certainly very busy actively managing many patients who had multiple chronic conditions. But working in the city, this sort of thing seems to be overwhelmingly done by non-GP specialists.

Maybe it’s a matter of access. In the country, there were no hospital outpatient clinics for most specialties, and the long wait for appointments in private rooms meant that there generally wasn’t much of a choice.

I managed my patients’ problems until they either went uneventfully for their regular specialist review, or something happened that required urgent input, in which case I was fortunate to have a direct line to most of the specialists whose help my patient might need.

Patient loyalty and specialist unavailability aren’t the same thing, but I’d like to think that my patients in the country trusted me to take care of them to the best of my ability and to know when I was out of my depth.

I spoke the other day to a metro GP who has been running his practice for 45 years and who told me: “My patients don’t want to go to see specialists! They trust me.”

And in his experienced hands, I’m certain they get care that is just as good.

The process of referring a patient to see a specialist is also worthy of some scrutiny.

Many patients seem to believe that writing a referral is akin to a magical, instantaneous process.

The GP waves their magic wand and within seconds a comprehensive, accurate letter pops out of the printer fully formed, no questions asked and no time expended.

This must be why so many patients expect us to perform this miracle rapidly and without asking to be paid for doing it.

We all know that a referral from a GP to a specialist doesn’t — or shouldn’t — just state, “Dear Dr X, thanks for seeing patient Y for ongoing management of disease Z,” although I’ve seen plenty that do.

Instead, it contains accurate information about the patient’s current medical problems, regular medications, and a summary of their recent health and the issues related to the problem at hand.

I’ve had patients get annoyed with me for wanting to speak with them as part of the process: “Can’t you just write it from my notes?”

Well, no I can’t.

Then there’s the stuff that happens after you produce the magical referral letter.

GP receptionist: “Mrs A just rang and asked if you could please change the referral from Dr B to Dr C, because Dr B isn’t available until January and Dr C won’t see the patient without a referral with their name on it.”

Patient: “I already saw Dr E last week, so could you please change the date on your referral to last Monday so I can get my Medicare rebate?”

Specialist receptionist: “Mr F is here to see Dr G, but his referral expired yesterday, so could you just write a quick referral because the appointment starts in five minutes?”

You check the file and realise that you wrote a referral letter to Dr G 366 days ago but Mr F didn’t see Dr G until three months later, so the referral is actually still valid, but you just write a new one anyway because it’s going to take longer to explain this situation than it will to simply comply.

And, of course, you don’t get paid for the time you spend on this idiocy. No wonder GPs are burning out.

Until very recently, I didn’t have much experience at all with referring to public hospital outpatient departments.

Then I started working at three different urgent care sites, each of which had its own, completely different process for referring to public hospital clinics.

The only hospital outpatient clinic you really need from urgent care is, of course, the fracture clinic. You probably already know where this is heading.

Clinic A’s local hospital’s ortho department has a designated ‘bone phone’ which a helpful registrar almost always answers.

Clinic B’s local hospital doesn’t have a bone phone, so you must call switchboard and ask to be put through to the ortho reg.

This mysterious individual almost never answers the phone, so it goes to messages (you can’t leave one), so you must hang up, call the switch again and start from the beginning.

Clinic C’s local hospital has a very simple rule: Clinic C can’t refer to the fracture clinic. At all. Instead, you are supposed to send the patient to the emergency department with a letter.

So what if this policy literally negates the whole point of urgent care clinics?

It’d be funny if it wasn’t so completely ridiculous.

Dr Rachel Glasson is a GP in Sydney, NSW.

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