What is a benefit of having the assistant schedule a consultation referral?

Under Review: No
Issued by Council (The Referral Consultation Process): January 1, 2010
Reissued by Council (Referral Consultation): January 1, 2017

1. A regulated member must recognize his or her limitations in the delivery of patient care and collaborate as appropriate with other healthcare providers for the benefit of the patient.
2. A regulated member must respect a patient’s reasonable request for referral to another healthcare provider for:
   1. a second opinion about the medical care provided; or
   2. services outside the scope of practice of the regulated member.
3. Notwithstanding clause 2, a regulated member is entitled to refuse to make a referral that, in his or her opinion, is unlikely to provide a clinical benefit.
4. When a regulated member believes that consultation by another healthcare provider is appropriate but the patient does not, the regulated member must:
   1. discuss with the patient and document in the patient’s record the difference of opinion and the implications of care; and
   2. continue to provide medical care that is in the best interest of the patient and within the scope of the regulated member’s practice.
5. A regulated member who refers or accepts a patient for consultation must inform the patient of the regulated member’s role and responsibilities in the patient’s care.
6. A regulated member who refers a patient for consultation must:
   1. discuss the purpose of the referral with the patient and confirm the patient’s agreement;
   2. inform the patient about any fees that may not be covered by the Alberta Health Care Insurance Plan if aware such fees are likely to be charged;
   3. evaluate and workup the patient within the regulated member’s scope of practice, including performing appropriate investigations; and
   4. make a timely, written request for consultation that includes the following information:
      1. patient’s name, Personal Health Number and contact information;
      2. regulated member’s name and contact information;
      3. name and contact information of the consultant or consulting service;
      4. date of referral;
      5. purpose of the referral, including but not limited to specifying if the referral is solely for the purpose of a third-party request;
      6. pertinent clinical information, including but not limited to the relevant investigation results; and
      7. expected consultation outcomes (e.g., medical opinion only, possible transfer of care, other).
7. A regulated member who refers a patient for an urgent and/or emergency consultation must:
   1. contact the consultant or emergency service directly to discuss the referral and provide pertinent clinical information; and
   2. to the extent possible, provide relevant documentation.
8. Notwithstanding clause 6(d), a regulated member may forego a written request for consultation in an urgent and/or emergent situation if the consultant or service agrees to accept care of the patient without a written request.
9. A regulated member who provides consultations must1:
   1. make information available to referring healthcare providers about the process for receiving requests for consultation and ensure:
      1. receipt of request is acknowledged to the referring healthcare provider within seven (7) days; and
      2. the decision to accept or deny a request is communicated to the referring healthcare provider within a time commensurate with the urgency of the request, but no longer than fourteen (14) days after the request was received;
   2. be reasonably available to respond to requests for consultation; and
   3. if denying a request for consultation, provide reasons and, whenever possible, alternative suggestions for care or consultation.
10. A regulated member who accepts a request for consultation must:
    1. contact the patient within a time commensurate with the urgency of the request, but not longer than fourteen (14) days after the request was received; and
       1. schedule an appointment date or, if an appointment date has not been determined, confirm the referral status with the patient and the referring healthcare provider at least every three (3) months;
       2. inform the patient of any fees not covered by the Alberta Health Care Insurance Plan;
    2. provide a written report directly to the referring healthcare provider no more than thirty (30) days after initially seeing the patient, that includes the following information:
       1. the identity of the consultant;
       2. the identity of the patient;
       3. the identity of the referring healthcare provider and, if known, the identity of the patient’s primary care physician;
       4. the date of the consultation;
       5. the purpose of the referral as understood by the consultant;
       6. information considered, including history, physical findings and investigations;
       7. diagnostic conclusions;
       8. treatments initiated, including medications prescribed;
       9. recommendations for follow-up by the referring healthcare provider;
       10. recommendations for continuing care by the consultant;
       11. recommendations for referral to other consultants; and
       12. advice given to the patient;
    3. inform the referring healthcare provider when a consultation will extend beyond one appointment and provide interim reports to the referring healthcare provider as required; and
    4. notify the patient and referring healthcare provider when the consultation is complete and patient care is being transferred back to the referring healthcare provider or transferred to another healthcare provider.
11. Notwithstanding clauses 6(d) and 10(b), a regulated member must respect a patient’s explicit request to withhold pertinent medical information and inform the consulting/referring healthcare provider when information has been withheld.
12. A regulated member who refers a patient for a non-urgent consultation must not send the same consultation request to multiple providers concurrently.
13. A regulated member must not:
    1. require a repeat referral for a patient with whom the regulated member already has an established physician-patient relationship2 for the purpose of gaining an additional consultation fee; or
    2. require a referral from a healthcare provider if the regulated member has arranged to see a patient without a referral.

1. The College will review complaints about management of consultation requests brought by other healthcare providers and patients.

2. In an established physician-patient relationship, both the regulated member and patient have a reasonable expectation the care provided will extend beyond a single encounter. Established physician-patient relationships include but are not limited to: a. longitudinal relationships, based on the identification of a regular attending physician or clinic; and

b. sessional relationships for a defined period of time, based on a presenting concern(s), referred consultation or identified medical condition.

The CPSA Standards of Practice are the minimum standards of professional behaviour and ethical conduct expected of all physicians registered in Alberta. Standards of practice are enforceable under the Health Professions Act and will be referenced in the management of complaints and in discipline hearings.

For questions or archived standards, policies and guidelines contact our Standards of Practice Advisor.

1. Mayer TR. Family practice referral patterns in a health maintenance organization. J Fam Pract. 1982;14(2):315–9. [PubMed] [Google Scholar]

2. Schmidt DD. Referral patterns in an individual family practice. J Fam Pract. 1977;5(3):401–3. [PubMed] [Google Scholar]

3. Geyman JP, Brown TC, Rivers K. Referrals in family practice: a comparative study by geographic region and practice setting. J Fam Pract. 1976;3(2):163–7. [PubMed] [Google Scholar]

4. Ludke RL. An examination of the factors that influence patient referral decisions. Med Care. 1982;20(8):782–96. [PubMed] [Google Scholar]

5. Schaffer WA, Holloman Fc., Jr Consultation and referral between physicians in new medical practice environments. Ann Intern Med. 1985;103(4):600–5. [PubMed] [Google Scholar]

6. Tenney JB, Brown TC, Rivers K. National ambulatory medical care survey: background and methodology. Vital Health Stat 2. 1974;61:74–1335. [Google Scholar]

7. Franks P, Clancy CM, Nutting PA. Defining Primary Care. Empirical analysis of the National Ambulatory Care Survey. Med Care. 1997;35(7):655–68. [PubMed] [Google Scholar]

8. Schneeweiss R, Ellsbury K, Hart LG, Geyman JP. The economic impact and multiplier effect of a family practice clinic on an academic medical center. JAMA. 1989;262(3):370–5. [PubMed] [Google Scholar]

9. Lee T, Pappius EM, Goldman L. Impact of inter-physician communication on the effectiveness of medical consultations. Am J Med. 1983;74(1):106–12. [PubMed] [Google Scholar]

10. Greenfield S, Nelson EC, Zubkoff M, et al. Variations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes Study. JAMA. 1992;267(12):1624–30. [PubMed] [Google Scholar]

11. Brock C. Consultation and referral patterns of family physicians. J Fam Pract. 1977;4(6):1129–37. [PubMed] [Google Scholar]

12. Calman NS, Hyman RB, Licht W. Variability in consultation rates and practitioner level of diagnostic certainty. J Fam Pract. 1992;35(1):31–8. [PubMed] [Google Scholar]

13. Gonzalez ML, Rizzo JA. Physician referrals and the medical market place. Med Care. 1991;29(10):1017–27. [PubMed] [Google Scholar]

14. Penchansky R, Fox D. Frequency of referral and patient characteristics in group practice. Med Care. 1970;8(5):368–85. [PubMed] [Google Scholar]

15. Pearson SD, Salem-Schatz S, Rucker M, Orav EJ, Pedan A. Variation in referral rates for acute low back pain in an HMO. J Gen Intern Med. 1995;10(suppl 4):76. Abstract. [Google Scholar]

16. Metcalfe DH, Sischy D. Patterns of referral from family practice. J Fam Pract. 1974;1(2):34–8. [PubMed] [Google Scholar]

17. Pearson SD, Salem-Schatz S, Rucker M, Orav EJ, Pedan A. HMO physician correlates of referral for acute low back pain. J Gen Intern Med. 1995;10(suppl 4):76. Abstract. [Google Scholar]

18. Strohmeyer Rw, Jr, Shula RJ. Physician’s liability for failure to consult with and/or refer a patient to a specialist. Indiana Med. 1988;81(1):45–7. [PubMed] [Google Scholar]

19. Mold JW, Stein HF. The cascade effect in the clinical care of patients. N Engl J Med. 1986;314(8):512–4. [PubMed] [Google Scholar]

20. Braham RL, Ron A, Ruchlin HS, Hollenberg JP, Pompei P, Charlson ME. Diagnostic test restraint and the specialty consultation. J Gen Intern Med. 1990;5(2):95–103. [PubMed] [Google Scholar]

21. Kahn KL, Kosecoff J, Chassin MR, Solomon DH, Brook RH. The use and misuse of upper gastrointestinal endoscopy. Ann Intern Med. 1988;109(8):664–70. [PubMed] [Google Scholar]

22. Winslow CM, Kosecoff JB, Chassin M, Kanouse DE, Brook RH. The appropriateness of performing coronary artery bypass surgery. JAMA. 1988;260(4):505–9. [PubMed] [Google Scholar]

23. Berczeller PH. The malignant consultation syndrome. Hosp Pract (Off Ed) 1991;26(9):29–31. [PubMed] [Google Scholar]

24. Eisenberg L. Treating depression and anxiety in primary care: closing the gap between knowledge and practice. N Engl J Med. 1992;326(16):1080–4. [PubMed] [Google Scholar]

25. Kashner TM, Rost K, Smith GR, Lewis S. An analysis of panel data: the impact of a psychiatric consultation letter on the expenditures and outcomes of care for patients with somatization disorder. Med Care. 1992;30(9):811–21. [PubMed] [Google Scholar]

26. O’Dell MW. Rehabilitation medicine consultation in persons hospitalized with AIDS: an analysis of thirty cases. Am J Phys Med Rehabil. 1993;72(2):90–6. [PubMed] [Google Scholar]

27. Turner BJ, McKee L, Fanning T, Markson LE. AIDS specialist versus generalist ambulatory care for advanced HIV infection and impact on hospital use. Med Care. 1994;32(9):902–16. [PubMed] [Google Scholar]

28. Bloomfield S, Farquhar JW. Is a specialist paediatric diabetic clinic better? Arch Dis Child. 1990;65(1):139–40. [PMC free article] [PubMed] [Google Scholar]

29. Ward MM, Leigh JP, Fries JF. Progression of functional disability in patients with rheumatoid arthritis: associations with rheumatology subspecialty care. Arch Intern Med. 1993;153(19):2229–37. [PubMed] [Google Scholar]

30. Hooker RS, Brown JB. Rheumatology referral patterns. HMO Pract. 1990;4(2):61–5. [PubMed] [Google Scholar]

31. Hickam DH, Smith SP, Joos SK. Natural history and management of psychologic problems in a general medicine clinic. J Gen Intern Med. 1994;9(suppl 2):56. Abstract. [Google Scholar]

32. Menken M, Behar R, Lee P. Neurology referral patterns. HMO Pract. 1990;4(2):57–60. [PubMed] [Google Scholar]

33. Grembowski DE, Cook K, Patrick DL, Roussel AE. Managed care and physician referral. Med Care Res Rev. 1998;55(1):3–31. [PubMed] [Google Scholar]

34. Chao J, Galazka S, Stange K, Fedirko T. A prospective review system of nonurgent consultation requests in a family medicine residency practice. Fam Med. 1993;25(9):570–5. [PubMed] [Google Scholar]

35. Roland M, Morris R. Are referrals by general practitioners influenced by the availability of consultants? BMJ. 1998;297(6648):599–600. [PMC free article] [PubMed] [Google Scholar]

36. Friedman E. Whither medical education? A sometimes inflexible system faces change. JAMA. 1993;270(12):1473–6. [PubMed] [Google Scholar]

37. Sick People in Managed Care Have Difficulty Getting Services and Treatment. New Survey Reports, Robert Wood Johnson Foundation, June 28, 1995.

38. Doyle RL. Section B—primary care guidelines. In: Healthcare Management Guidelines. Milliman and Robertson; 1991.

39. Hurley RE, Freund DA, Gage BJ. Gatekeeper effects on patterns of physician use. J Fam Pract. 1991;32(2):167–74. [PubMed] [Google Scholar]

40. Cain JM, Jonsen AR. Specialists and generalists in obstetrics and gynecology: conflicts of interest in referral and an ethical alternative. Womens Health Issues. 1992;2(3):137–45. [PubMed] [Google Scholar]

41. Langley GR, MacLellan AM, Sutherland HJ, Till JE. Effect of nonmedical factors on family physicians’ decisions about referral for consultation. Can Med Assoc J. 1992;147(5):659–66. [PMC free article] [PubMed] [Google Scholar]

42. Fitzpatrick R, Hopkins A. Referrals to neurologists for headaches not due to structural disease. J Neurol Neurosurg Psychiatry. 1981;44(12):1061–7. [PMC free article] [PubMed] [Google Scholar]

43. Greenfield S, Linn LS, Purtill N, Young RT. Reverse consultations: the profiles of patients referred from subspecialists to generalists. J Chronic Dis. 1983;36(12):883–9. [PubMed] [Google Scholar]

44. Leonard I, Babbs C, Creed F. Psychiatric referrals within the hospital—the communication process. J R Soc Med. 1990;83(4):241–4. [PMC free article] [PubMed] [Google Scholar]

45. Kuo D, Gifford DR, Stein MD. Curbside consultation practices and attitudes among primary care physicians and medical subspecialists. JAMA. 1998;280(10):905–9. [PubMed] [Google Scholar]

46. Keating NL, Zaslavsky AM, Ayanian JZ. Physicians’ experiences and beliefs regarding informal consultation. JAMA. 1998;280(10):900–4. [PubMed] [Google Scholar]

47. Hjortdahl P, Borchgrevnik CF. Continuity of care: influence of general practitioners’ knowledge about their patients on use of resources in consultations. BMJ. 1991;303(6811):1181–4. [PMC free article] [PubMed] [Google Scholar]

48. Armstrong D, Fry J, Armstrong P. Doctors’ perceptions of pressure from patients for referral. BMJ. 1991;302(6786):1186–8. [PMC free article] [PubMed] [Google Scholar]

49. Eisenberg JM. Physician utilization: the state of research about physicians’ practice patterns. Med Care. 1985;23(5):461–83. [PubMed] [Google Scholar]

50. Marton KI, Sox Hc, Jr, Wasson J, Duisenberg CE. The clinical value of the upper gastrointestinal tract roentgenogram series. Arch Intern Med. 1980;140(2):191–5. [PubMed] [Google Scholar]

51. Lin CT, Albertson G, Swaney R, Anderson S, Anderson R. Patient expectations for subspecialty referral in an academic managed care system. J Gen Intern Med. 1998;13(suppl):65. Abstract. [Google Scholar]

52. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expectations for care during office visits. J Gen Intern Med. 1994;9(2):75–81. [PubMed] [Google Scholar]

53. Byrd JC, Moskowitz MA. Outpatient consultation: interaction between the general internist and the specialist. J Gen Intern Med. 1987;2(2):93–8. [PubMed] [Google Scholar]

54. McPhee SJ, Lo B, Saika GY, Meltzer R. How good is communication between primary care physicians and subspecialty consultants? Arch Intern Med. 1984;144(6):1265–8. [PubMed] [Google Scholar]

55. Cummins RO, Smith RW, Inui TS. Communication failure in primary care: failure of consultants to provide follow-up information. JAMA. 1980;243(16):1650–2. [PubMed] [Google Scholar]

56. Lloyd M, Bradford C, Webb S. Non-attendance at outpatient clinics: is it related to the referral process? Fam Pract. 1993;10(2):111–7. [PubMed] [Google Scholar]

57. Mantyjarvi M. No-show patients in an ophthalmological out-patient department. Acta Ophthalmol (Copenh) 1994;72(3):284–9. [PubMed] [Google Scholar]

58. Ross JD, McIver A, Blakely A, Dalrymple J, Peacock W, Wallis C. Why do patients default from follow-up at a genitourinary clinic?: a multivariate analysis. Genitourin Med. 1995;71(6):393–5. [PMC free article] [PubMed] [Google Scholar]

Page 2

Generalists’ Reasons for Referral