Vol. 8, No. 4 Printed in Great Britain
. Family Practice © Oxford University Press 1991
Factors Influencing General Practitioners' Referral Decisions JOHN NEWTON, VIC HAYES AND ALLEN HUTCHINSON Newton J , Hayes V and Hutchinson A. Factors influencing general practitioners' referral decisions. Fami/y Practice 1991; 8: 308-313. This paper presents some findings from a small scale qualitative study of referral decision making conducted in south-east Northumberland in igSS-^. The study was prompted by an interest in variability in referral rates and the view that existing studies had not attempted to understand referral from the perspective of those involved in making the decisions. Our findings suggest that such understandings are crucial in the analysis of referral decisions and in any policy making initiatives designed to influence the pattern of referring.
PREVIOUS STUDIES OF REFERRAL Studies of general practitioner referrals have typically been grounded in a positivist view of the world. According to this perspective phenomena (whether they be natural or social) are identified, defined, and measured prior to variations in their incidence being accounted for in terms of factors derived from previously proven principles. Referrals, therefore, are counted, rates constructed, and variations analysed in terms of doctor, patient, or practice characteristics. To date, this approach has failed to explain the acknowledged variation in referral rates between doctors. Early studies'12 involved small numbers of doctors within single practices and produced speculative and individualistic explanations from which it was difficult to draw any patterns or generalizations. Using a much larger sample Coulter et al. categorised 18000 cases of referral using eight pre-determined reasons for referral.3 Although the study drew attention to the scale, nature, diversity, and objectives of referral it provided little in the way of explaining what was involved in making referral decisions. A few studies have looked at referral as a process. Dowie4 developed a model of referral decision making based on doctors' cognitive processes; including their confidence and their consideration of the probabilities associated with life threatening illnesses. While agreeing that psychological factors are an integral component of any model of decision making we would argue
Centre for Health Services Research, School of Health Care Sciences, The University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne NE2 4AA, UK.
308
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argue that referral needs to be understood from the perspective of those involved in the process. The findings of our qualitative study of referral suggest that such understandings are crucial in the analysis of referral decisions and in any policy initiatives which attempt to influence the pattern of referring.
INTRODUCTION For some time now general practitioner referrals to hospital have been a prime focus of attention for health care researchers. The interest, which dates back to the 1960s1 is associated with three related concerns. First, it has become increasingly apparent that there is variation in rates of referral between individual doctors. The knowledge that variation exists has stimulated a number of studies designed to account for the recorded patterns. Second, referrals to secondary care trigger the use of expensive and finite NHS resources and there has thus been some managerial incentive to understand and explain variation. Finally, the issue of variation has aroused the interest of those concerned with the quality of care. If some doctors are 'low' referrers and others 'high' referrers how does this affect patients? Are some patients being denied access to specialist care by doctors who for whatever reason 'hang on' to their patients? Are other patients being subjected to unnecessary procedures and investigations by doctors who—again for a variety of possible reasons—refer a high proportion of their patients to their hospital colleagues? The results of studies conducted to date have provided only limited insights. No one has demonstrated significant relationships between patient, doctor, and practice characteristics and variation in referral rates. The view developed in this paper is that the failure of research to adequately explain why variation exists can in part be attributed to the way in which the problem has been conceptualized and approached. We shall
GP REFERRAL DECISIONS
that social and cultural variables may play an equally important role. Drawing on Dowie's work, Wilkin and Smith5 argue that the failure of existing studies to account for variation in referral rates is associated with a failure to distinguish between different types of referral. They go on to present a model of referral decision making which accommodates a broader range of types without, however, presenting any empirical data. Nevertheless, their paper recognizes that referral is a complex process which involves the interaction of both social and psychological factors.
Study Methodology The findings reported below are based on a qualitative analysis of interviews with 15 general practitioners who were randomly selected from a stratified sample of practices in south-east Northumberland. The sample ensured a range of practice size from two partners to six partners, working in rural and urban settings on the edge of a major conurbation. Each of the participating doctors was interviewed on two occasions. On the first occasion the interview was based on three randomly selected referrals made in the four weeks prior to the interview, the cases being selected by the interviewer from the total number of the referrals for that period. Forty-five cases were reviewed, ranging in seriousness from the non-life threatening to people with terminal illness. The format of these interviews was to move from matters specific to the selected cases to general issues about referral that emerged as the investigation progressed. Thus the first round interviews were guided only by a framework, which was added to as each interview brought in new issues or ideas. The interviewer was therefore able to follow participants ideas and concerns through in considerable detail. The second round of interviews was more structured, clarifying and expanding on issues discussed in the first round. Interviewing was chosen as the means of data collection since the lack of existing knowledge about factors influencing referral decisions required an exploratory
method capable of yielding ideas and insights. Unlike survey methods or studies in medical science, qualitative researchers do not typically begin with an explicit theoretical model and there is rarely any attempt to verify and validate pre-formulated hypotheses. Instead, the logic of inquiry is the inductive one described by Glaser and Strauss* in which hypotheses emerge from the analysis of initial cases and are subsequently tested and modified in the light of further evidence. This is a logic of inquiry which has been compared to the work of a mapmaker: 'Their job is to make a set of integrated observations on a given topic and place them in an analytic framework.'7 Our framework began by coding the transcripts of the 30 interviews which amounted to over 1000 pages of text. Initially, this was done in an open ended way by the three investigators working independently. The text of each interview was read and salient sections would be marked as instances of whatever concept the coder thought appropriate to apply to that fragment. A typical case might be where a doctor was talking about the role of the patient in a referral decision. That part of the text would then be labelled 'patient pressure' (Code: Pp) or 'patient involvement' (Pi). Where the coders agreed on these labels the relevant text would be given a definitive code. Subsequently, it was possible with the word processing programme we were using to collect all instances of fragments with a particular code into one file in order to compare them. The object of the analysis was to examine the coded data set for patterns and themes. Some of the themes were prompted by our knowledge of the work of other researchers and commentators on referral. Aulber's paper,8 for example, prompted us to organize our materials in terms of 'doctor associated' and 'patient associated' factors. Other themes—according to the logic of qualitative methods—emerged out of the analysis of the data itself. The distinction between clinical and non-clinical factors was one such emergent theme. THE INTERACTION OF CLINICAL AND NON-CLINICAL FACTORS IN REFERRAL DECISION MAKING Patients are referred to see hospital consultants for a variety of reasons: further investigation; treatment for already diagnosed conditions; diagnostic advice; and so on. The decision to refer is usually made when the doctor has determined that the problem can no longer be dealt with given his or her knowledge, skill, time, or resources. Apart from some very 'straightforward' referrals, however (e.g. to remove lumps and bumps, carry out some specialist investigation; or provide treatment only available at a hospital) we found that the decision to refer is rarely, if ever, based on clinical factors alone. Many of the cases we analysed were constituted by a complex interaction of clinical and nonclinical factors. Some of the non-clinical factors relate to the personal characteristics of the referring doctor: for example,
Downloaded from fampra.oxfordjournals.org at OCLC on August 16, 2015
THE PRESENT STUDY Underlying the methods of investigation and analysis which are reported below is a view of referral decision making which differs quite sharply from the positivist approach we outlined earlier. For us referral is a type of social action which can be best understood by interpreting the meanings and motives of those involved. Thus, when a patient is referred to see a consultant this means that a doctor—often as a result of several consultations with that patient (perhaps over an extended period)—has come to define a set of symptoms together with other information in a particular way. Each referral decision may depend on the way in which unique constellations of factors are interpreted. Studying referral, therefore, requires that investigators get as close as they can to the interactional processes through which it is constituted.
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WHERE THE PATIENT DOES NOT 'NEED' REFERRING This kind of situation arose when the clinical features of the case did not in themselves indicate that a referral was the next step. It may be a case, for example, where the doctor is sure that there is no serious pathology but the patient remains unconvinced. In these circumstances the patient may request—more or less overtly— that they would like to be referred. The outcome of situations such as this often depends on the doctor's attitude to patients' rights to a second opinion and/or to the manner in which such a request is made. In one interview a doctor declared himself wholly supportive of the patient's right to a second opinion but when asked what he would do if a patient demanded to be referred implied that he would be affronted. Second opinions were to be requested rather than demanded! It is not always the patient who initiates 'nonmedical' referrals. We found a variety of cases where it was the doctor who wanted to refer a patient even though an objective or external reading of the clinical facts would have suggested otherwise. Three instances can be cited. Firstly, a patient suffering from a chronic illness may be difficult or demanding and is referred as one doctor put it to share the burden of care. In the extract below the doctor is recalling a case from his previous practice: "(it was) . . . a family who seemed to be absolutely certain that there was something drastically wrong with their child, and you could see that there was nothing wrong; and I ended up referring him to a
consultant because I couldn't deal with the problem. He was supposed to be vomiting everything up . . . but was gaining weight rapidly and running round the place as large as life. It was hard to imagine—I had to believe that he was vomiting everything back but the parents got so demanding that I had to refer them just to stop them coming back to me; to give me a break." (Interview no. 10) Secondly, doctors may refer a patient to cover themselves in case of possible involvement in legal proceedings. In the following extract a trauma case is recalled: "This was to an orthopaedic surgeon. This girl had fallen on her hand . . . er . . . probably in August, and she'd complained of pain ever since. She'd come to see me for the first time two months after the accident. She was very tender at the end of her ulna bone and I felt there was probably a fracture there. I had an X-ray done, and it did show a fracture which hadn't healed. And I asked for an orthopaedic opinion thinking that there's nothing further to be done anyway, but I really wanted to cover myself . . . Being the hand, if there was to be loss of movement I didn't want to be taken to court for not having referred her." (Interview no. 4) Thirdly, doctors may refer patients 'to test the service': " . . . a lot of the time you are really just testing out the service . . . you want to know what sort of service is offered by a particular consultant for a particular condition." (Interview no. 12) Where the Doctor is Not Sure Whether the Patient Needs Referring In all of the above cases the clinical signs do not automatically indicate the necessity for a referral: yet the patient is referred. The need for referral in these instances is defined in terms of social or psychological factors, and such factors are taken as warrant enough for the decision. But what of cases where the doctor is not sure whether the patient needs referring? A number of factors emerged as influential in making these decisions. Intra-practice Referral Most of the doctors we interviewed said that they were accustomed to discussing patients with other partners in the practice. This form of consultation occurred with varying degrees of formality. In some practices it amounted to no more than having a word with a colleague over coffee, or inviting the colleague to have a look at something during a consultation. In only two practices were patients actually passed on to acknowledged specialists, but this was felt to be a quick way of resolving doubts about a case, and was in one case described as saving referrals. The Management of Uncertainty Medical practice has been described as being saturated by uncertainties: "Whether a physician is defining a disease, making a diagnosis, selecting a procedure,
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their concern about how the consultant will evaluate the referral, their anxiety about the possible legal implications of a case, their propensity to take risks, or to tolerate uncertainty. Another set of non-clinical factors relate to the patient, particularly their expectations, circumstances, and ability to assert their views and feelings. And a major non-clinical variable concerns the relationships between doctor and patient and between doctor and consultant. Of course, general practitioners are aware of the role that non-clinical factors play in referral decision making: " . . . one's always thinking about who they (patients) are, who's with them, and who they relate to. It's one of the things that one just learns to do, it's part of the subpractice." (Interview no. 9) Sometimes the inter-relationship between clinical and non-clinical is not so clear cut in the mind of the doctor: " . . . I think that all the things don't flood in at once as a definite list. I'd be quite capable of making a list of 14 points which influence people's referrals, but they don't come to me like that at all: they permeate in." (Interview no. 2) For analytical purposes, however, we did seek to distinguish between the different kinds of factor. One of the outcomes of our analysis was the identification of a number of typical circumstances in which these complex interactions of factors took place. Two such examples are discussed in the next section.
GP REFERRAL DECISIONS observing outcomes, assessing probabilities . . . or putting it all together she/he is walking on very slippery terrain. It is difficult for non-physicians, and for many physicians, to appreciate how complex these tasks are, how poorly we understand them, and how easy it is for honest people to come to different conclusions." 9 The doctors in our study followed a range of strategies when uncertain about a case. Some referred straight away 'just in case'; while others adopted a wait and see approach: they used time. Clearly, the particular approach chosen will vary according to the personality of the doctor, and in particular their tolerance of uncertainty/propensity to take risks. We did not attempt to make any assessment of these variables in our study but they have been discussed by other investigators.10
The Doctor's Knowledge and Experience There are two aspects of the doctor's knowledge and experience we've found to be influential in referral decision making: having particular knowledge or
DISCUSSION The findings reported here lend empirical support to discussions of referral such as those by Aulbers" which identify the range of possible influences but do not themselves collect and analyse data to demonstrate the validity of their conceptual schemes. We have seen, therefore, that referral decisions are influenced by four groups of factors (Table 1). Since many of these factors have little to do with doctors' reasoning processes we are led to suggest that an approach such as the one adopted here represents a useful complement to approaches which concentrate on the purely cognitive aspects of referral decision making. We would agree with Dowie and Elstein who have said that "clinical decisions are not isolated cognitive events." 12 In other words, decisions about the referral of patients should be seen as integral to the context in which the decision maker operates. This context might be described as 'the environment of decision making'. 13 In large part this environment consists of a number of interacting components which form an active and conscious part
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The Doctor's Relationship with Consultants Most of the doctors we interviewed knew the consultants to whom they referred. They felt that this could influence their decision making about cases which fell into the 'not sure' category in three ways: firstly, it could facilitate an informal contact. That is, it meant that a doctor could telephone a consultant to obtain an opinion about the appropriateness of referring a problematic case: " . . . often you might get in ophthalmology conditions in which an acute red eye is not responding to straightforward antibiotic therapy and you may think that they've got an iritis for example. But by and large, what you might do on that occasion is phone the ophthalmologist on call that day and discuss that with him." (Interview no. 7) Secondly, it enabled doctors to know what consultants expect. When a doctor has referred patients on previous occasions and has thereby come to know how the consultant has responded, s/he can assess, for example, whether an early referral of a patient whose problem is not straightforward would be appropriate. Thirdly, it protected the doctor's self esteem. At many points doctors told us that they were concerned about how referral reflected on them as practitioners. They were mindful, for example, of not wasting consultants' time, or felt guilty about referring patients who they might well have continued to manage themselves. Knowing a consultant, it was argued, meant that a certain kind of taken for grantedness could develop between the two parties—a doctor could refer a problem case knowing that the consultant would understand that there would be a good reason for the referral: " . . . I think if they know you vaguely and they know the types of things you refer, they know that you are not going to refer rubbish in that you do have a reason behind referring somebody and you are not just sending everybody that you have in the surgery just for the sake of it." (Interview no. 8)
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interests in a medical specialism; and learning from experience. Doctors often said that they had particular interests within the field of general practice and different levels of knowledge. Generally, where a doctor mentioned a speciality (e.g. eyes, skins, etc.), this was thought to reduce the rate of referring in that area. In explaining this relationship the most frequently cited factor was that of confidence: "If you've worked in an eye department for two or three years you are going to be pretty confident in that area." (Interview no. 12) "If you're interested in a field, hopefully you've probably got more confidence so you can actually deal with them better . . . er . . . without the need for a consultant's opinion." (Interview no. 5) The same doctor, however, inserted the following proviso: " . . . as you deal with a field in particular, sometimes you attract . . . er . . . people within the practice to come and see you for that particular speciality . . . um, for that reason you probably have to refer a few more o n . " (Interview no. 5) The second aspect concerns knowledge gained through experience. Many of the doctors interviewed said that they referred fewer patients now than they did when they first qualified. The typical explanation ran as follows: "I think its increase in experience and having seen something before and having had a consultant opinion about it in the past." (Interview no. 8) "As time goes by you mature a little and learn what does require referral and when." (Interview no. 7) This learning process did not always occur naturally. Some doctors saw referral as being in part an educational process: "I think it is an absolutely legitimate part of the health service to use a consultant to learn from. So if you're a trainee or a young principal, and you're not sure about a condition or a rash or something then its legitimate to send that patient up to see a consultant." (Interview no. 2)
312
FAMILY PRACTICE—AN INTERNATIONAL JOURNAL TABLE 1
Factors influencing general practitioner's referral decisions REFEFSWL DECISIONS
Factors
Krudural Factore
PHlanlAstodalad Factora
pQpuHi conctplons
2 Doctors'corapfan of c m
nleqarimca
5 PflMpliiin
CONCLUSION Since referral to secondary care results in the consumption of scarce resources health services managers and policy makers have been keen for recorded variations in referral rates to be explained. Such explanations might then serve as the basis of policies designed to exercise more control over referral. The findings of this study suggest that we are far from being able to explain
Owl
5 CorauBilon irnt
patterns of referral and that a perspective which begins by attempting to understand the meanings and motives of those involved in the process of referral may be more fruitful than the positivist paradigm which has influenced much of the research in this field. The indications are that a large number of referral decisions are not only difficult to make from a clinical point of view but are also further complicated by the personal values, skills, and experiences of those involved as well as the nature of relationships between them. ACKNOWLEDGEMENTS We would like to express our thanks to the fifteen general practitioners who took part in the study; to the Northumberland LMC for their support; to the Primary Health Care Development Fund for funding the study; and to the Department of Health for supporting Dr Hutchinson. 1
2
3
4
REFERENCES Storey CJH. A hospital outpatients study. J R Coll Gen Pract 1961; 4: 214-222. Morrell DC, Gage HG, Robinson A. RefeiTal to hospital by general practitioners. J R Coll Pract 1971; 21: 77-85. Coulter A, Noone A, Goldacre M. General practitioners' referrals to specialist outpatients clinics. Br Med J 1989; 299: 304-308. Dowie R. General practitioners and consultants—a study of outpatient referrals. London, King Edward's Hospital Fund for London 1983.
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of the doctor's decision making. An important interaction has been identified between clinical and nonclinical aspects of presenting problems. Having identified these factors we would not hypothesize that any of them would operate to increase or decrease referral decisions in a uniform or predictable way. Thus, a good doctor-patient relationship might facilitate openness in communications and help doctors reassure patients in cases where the doctor does not think that a referral is necessary. The same good relationship may also encourage patients to be less inhibited in making a request for referral in the first place. Similarly, where doctors possess some specialist knowledge this could reduce the number of referrals they make to consultants in that speciality because they know what can be done for patients and what is available. At the same time where less knowledgeable partners are aware of a colleague's specialist interests this may prompt them to steer patients in that colleague's direction, and a proportion of these patients may then be referred.
Cowrt
GP REFERRAL DECISIONS 3
6
7
8
Wilkin D, Smith A. Explaining variations in general practitioner referrals to hospital. Family Practice 1987; 4: 160-169. Glaser B, Strauss A. The Discovery of Grounded Theory. Chicago, Aldine, 1967. Schwartz H, Jacobs J. Qualitative sociology: A method to the madness. New York, Free Press, 1979; 289. Aulbers BJM. Factors influencing referrals by General Practitioners to Consultants. In Sheldon M, Brooke J, Rector A, (eds). Decision making in general practice. London: MacMillan 1985.
9
10
11 12 13
313
Eddy DM, Variations in physician practice. The role of uncertainty. In Dowie J, Elstein A. Professional Judgement—A Reader in Clinical Decision Making, Cambridge, Cambridge University Press; p 2. Cummins RO, Jarman B, White PM. Do general practitioners have different "referral thresholds?" BrMedJ 1981; 282: 1037-1039. Aulbers BJM, op. cit. Dowie J, Elstein A. op cit. Introduction, p 27. Cook S, Slack N. Making management decisions. London, Prentice Hall, 1984.
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. Family Practice © Oxford University Press 1991
Factors Influencing General Practitioners' Referral Decisions JOHN NEWTON, VIC HAYES AND ALLEN HUTCHINSON Newton J , Hayes V and Hutchinson A. Factors influencing general practitioners' referral decisions. Fami/y Practice 1991; 8: 308-313. This paper presents some findings from a small scale qualitative study of referral decision making conducted in south-east Northumberland in igSS-^. The study was prompted by an interest in variability in referral rates and the view that existing studies had not attempted to understand referral from the perspective of those involved in making the decisions. Our findings suggest that such understandings are crucial in the analysis of referral decisions and in any policy making initiatives designed to influence the pattern of referring.
PREVIOUS STUDIES OF REFERRAL Studies of general practitioner referrals have typically been grounded in a positivist view of the world. According to this perspective phenomena (whether they be natural or social) are identified, defined, and measured prior to variations in their incidence being accounted for in terms of factors derived from previously proven principles. Referrals, therefore, are counted, rates constructed, and variations analysed in terms of doctor, patient, or practice characteristics. To date, this approach has failed to explain the acknowledged variation in referral rates between doctors. Early studies'12 involved small numbers of doctors within single practices and produced speculative and individualistic explanations from which it was difficult to draw any patterns or generalizations. Using a much larger sample Coulter et al. categorised 18000 cases of referral using eight pre-determined reasons for referral.3 Although the study drew attention to the scale, nature, diversity, and objectives of referral it provided little in the way of explaining what was involved in making referral decisions. A few studies have looked at referral as a process. Dowie4 developed a model of referral decision making based on doctors' cognitive processes; including their confidence and their consideration of the probabilities associated with life threatening illnesses. While agreeing that psychological factors are an integral component of any model of decision making we would argue
Centre for Health Services Research, School of Health Care Sciences, The University of Newcastle upon Tyne, 21 Claremont Place, Newcastle upon Tyne NE2 4AA, UK.
308
Downloaded from fampra.oxfordjournals.org at OCLC on August 16, 2015
argue that referral needs to be understood from the perspective of those involved in the process. The findings of our qualitative study of referral suggest that such understandings are crucial in the analysis of referral decisions and in any policy initiatives which attempt to influence the pattern of referring.
INTRODUCTION For some time now general practitioner referrals to hospital have been a prime focus of attention for health care researchers. The interest, which dates back to the 1960s1 is associated with three related concerns. First, it has become increasingly apparent that there is variation in rates of referral between individual doctors. The knowledge that variation exists has stimulated a number of studies designed to account for the recorded patterns. Second, referrals to secondary care trigger the use of expensive and finite NHS resources and there has thus been some managerial incentive to understand and explain variation. Finally, the issue of variation has aroused the interest of those concerned with the quality of care. If some doctors are 'low' referrers and others 'high' referrers how does this affect patients? Are some patients being denied access to specialist care by doctors who for whatever reason 'hang on' to their patients? Are other patients being subjected to unnecessary procedures and investigations by doctors who—again for a variety of possible reasons—refer a high proportion of their patients to their hospital colleagues? The results of studies conducted to date have provided only limited insights. No one has demonstrated significant relationships between patient, doctor, and practice characteristics and variation in referral rates. The view developed in this paper is that the failure of research to adequately explain why variation exists can in part be attributed to the way in which the problem has been conceptualized and approached. We shall
GP REFERRAL DECISIONS
that social and cultural variables may play an equally important role. Drawing on Dowie's work, Wilkin and Smith5 argue that the failure of existing studies to account for variation in referral rates is associated with a failure to distinguish between different types of referral. They go on to present a model of referral decision making which accommodates a broader range of types without, however, presenting any empirical data. Nevertheless, their paper recognizes that referral is a complex process which involves the interaction of both social and psychological factors.
Study Methodology The findings reported below are based on a qualitative analysis of interviews with 15 general practitioners who were randomly selected from a stratified sample of practices in south-east Northumberland. The sample ensured a range of practice size from two partners to six partners, working in rural and urban settings on the edge of a major conurbation. Each of the participating doctors was interviewed on two occasions. On the first occasion the interview was based on three randomly selected referrals made in the four weeks prior to the interview, the cases being selected by the interviewer from the total number of the referrals for that period. Forty-five cases were reviewed, ranging in seriousness from the non-life threatening to people with terminal illness. The format of these interviews was to move from matters specific to the selected cases to general issues about referral that emerged as the investigation progressed. Thus the first round interviews were guided only by a framework, which was added to as each interview brought in new issues or ideas. The interviewer was therefore able to follow participants ideas and concerns through in considerable detail. The second round of interviews was more structured, clarifying and expanding on issues discussed in the first round. Interviewing was chosen as the means of data collection since the lack of existing knowledge about factors influencing referral decisions required an exploratory
method capable of yielding ideas and insights. Unlike survey methods or studies in medical science, qualitative researchers do not typically begin with an explicit theoretical model and there is rarely any attempt to verify and validate pre-formulated hypotheses. Instead, the logic of inquiry is the inductive one described by Glaser and Strauss* in which hypotheses emerge from the analysis of initial cases and are subsequently tested and modified in the light of further evidence. This is a logic of inquiry which has been compared to the work of a mapmaker: 'Their job is to make a set of integrated observations on a given topic and place them in an analytic framework.'7 Our framework began by coding the transcripts of the 30 interviews which amounted to over 1000 pages of text. Initially, this was done in an open ended way by the three investigators working independently. The text of each interview was read and salient sections would be marked as instances of whatever concept the coder thought appropriate to apply to that fragment. A typical case might be where a doctor was talking about the role of the patient in a referral decision. That part of the text would then be labelled 'patient pressure' (Code: Pp) or 'patient involvement' (Pi). Where the coders agreed on these labels the relevant text would be given a definitive code. Subsequently, it was possible with the word processing programme we were using to collect all instances of fragments with a particular code into one file in order to compare them. The object of the analysis was to examine the coded data set for patterns and themes. Some of the themes were prompted by our knowledge of the work of other researchers and commentators on referral. Aulber's paper,8 for example, prompted us to organize our materials in terms of 'doctor associated' and 'patient associated' factors. Other themes—according to the logic of qualitative methods—emerged out of the analysis of the data itself. The distinction between clinical and non-clinical factors was one such emergent theme. THE INTERACTION OF CLINICAL AND NON-CLINICAL FACTORS IN REFERRAL DECISION MAKING Patients are referred to see hospital consultants for a variety of reasons: further investigation; treatment for already diagnosed conditions; diagnostic advice; and so on. The decision to refer is usually made when the doctor has determined that the problem can no longer be dealt with given his or her knowledge, skill, time, or resources. Apart from some very 'straightforward' referrals, however (e.g. to remove lumps and bumps, carry out some specialist investigation; or provide treatment only available at a hospital) we found that the decision to refer is rarely, if ever, based on clinical factors alone. Many of the cases we analysed were constituted by a complex interaction of clinical and nonclinical factors. Some of the non-clinical factors relate to the personal characteristics of the referring doctor: for example,
Downloaded from fampra.oxfordjournals.org at OCLC on August 16, 2015
THE PRESENT STUDY Underlying the methods of investigation and analysis which are reported below is a view of referral decision making which differs quite sharply from the positivist approach we outlined earlier. For us referral is a type of social action which can be best understood by interpreting the meanings and motives of those involved. Thus, when a patient is referred to see a consultant this means that a doctor—often as a result of several consultations with that patient (perhaps over an extended period)—has come to define a set of symptoms together with other information in a particular way. Each referral decision may depend on the way in which unique constellations of factors are interpreted. Studying referral, therefore, requires that investigators get as close as they can to the interactional processes through which it is constituted.
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WHERE THE PATIENT DOES NOT 'NEED' REFERRING This kind of situation arose when the clinical features of the case did not in themselves indicate that a referral was the next step. It may be a case, for example, where the doctor is sure that there is no serious pathology but the patient remains unconvinced. In these circumstances the patient may request—more or less overtly— that they would like to be referred. The outcome of situations such as this often depends on the doctor's attitude to patients' rights to a second opinion and/or to the manner in which such a request is made. In one interview a doctor declared himself wholly supportive of the patient's right to a second opinion but when asked what he would do if a patient demanded to be referred implied that he would be affronted. Second opinions were to be requested rather than demanded! It is not always the patient who initiates 'nonmedical' referrals. We found a variety of cases where it was the doctor who wanted to refer a patient even though an objective or external reading of the clinical facts would have suggested otherwise. Three instances can be cited. Firstly, a patient suffering from a chronic illness may be difficult or demanding and is referred as one doctor put it to share the burden of care. In the extract below the doctor is recalling a case from his previous practice: "(it was) . . . a family who seemed to be absolutely certain that there was something drastically wrong with their child, and you could see that there was nothing wrong; and I ended up referring him to a
consultant because I couldn't deal with the problem. He was supposed to be vomiting everything up . . . but was gaining weight rapidly and running round the place as large as life. It was hard to imagine—I had to believe that he was vomiting everything back but the parents got so demanding that I had to refer them just to stop them coming back to me; to give me a break." (Interview no. 10) Secondly, doctors may refer a patient to cover themselves in case of possible involvement in legal proceedings. In the following extract a trauma case is recalled: "This was to an orthopaedic surgeon. This girl had fallen on her hand . . . er . . . probably in August, and she'd complained of pain ever since. She'd come to see me for the first time two months after the accident. She was very tender at the end of her ulna bone and I felt there was probably a fracture there. I had an X-ray done, and it did show a fracture which hadn't healed. And I asked for an orthopaedic opinion thinking that there's nothing further to be done anyway, but I really wanted to cover myself . . . Being the hand, if there was to be loss of movement I didn't want to be taken to court for not having referred her." (Interview no. 4) Thirdly, doctors may refer patients 'to test the service': " . . . a lot of the time you are really just testing out the service . . . you want to know what sort of service is offered by a particular consultant for a particular condition." (Interview no. 12) Where the Doctor is Not Sure Whether the Patient Needs Referring In all of the above cases the clinical signs do not automatically indicate the necessity for a referral: yet the patient is referred. The need for referral in these instances is defined in terms of social or psychological factors, and such factors are taken as warrant enough for the decision. But what of cases where the doctor is not sure whether the patient needs referring? A number of factors emerged as influential in making these decisions. Intra-practice Referral Most of the doctors we interviewed said that they were accustomed to discussing patients with other partners in the practice. This form of consultation occurred with varying degrees of formality. In some practices it amounted to no more than having a word with a colleague over coffee, or inviting the colleague to have a look at something during a consultation. In only two practices were patients actually passed on to acknowledged specialists, but this was felt to be a quick way of resolving doubts about a case, and was in one case described as saving referrals. The Management of Uncertainty Medical practice has been described as being saturated by uncertainties: "Whether a physician is defining a disease, making a diagnosis, selecting a procedure,
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their concern about how the consultant will evaluate the referral, their anxiety about the possible legal implications of a case, their propensity to take risks, or to tolerate uncertainty. Another set of non-clinical factors relate to the patient, particularly their expectations, circumstances, and ability to assert their views and feelings. And a major non-clinical variable concerns the relationships between doctor and patient and between doctor and consultant. Of course, general practitioners are aware of the role that non-clinical factors play in referral decision making: " . . . one's always thinking about who they (patients) are, who's with them, and who they relate to. It's one of the things that one just learns to do, it's part of the subpractice." (Interview no. 9) Sometimes the inter-relationship between clinical and non-clinical is not so clear cut in the mind of the doctor: " . . . I think that all the things don't flood in at once as a definite list. I'd be quite capable of making a list of 14 points which influence people's referrals, but they don't come to me like that at all: they permeate in." (Interview no. 2) For analytical purposes, however, we did seek to distinguish between the different kinds of factor. One of the outcomes of our analysis was the identification of a number of typical circumstances in which these complex interactions of factors took place. Two such examples are discussed in the next section.
GP REFERRAL DECISIONS observing outcomes, assessing probabilities . . . or putting it all together she/he is walking on very slippery terrain. It is difficult for non-physicians, and for many physicians, to appreciate how complex these tasks are, how poorly we understand them, and how easy it is for honest people to come to different conclusions." 9 The doctors in our study followed a range of strategies when uncertain about a case. Some referred straight away 'just in case'; while others adopted a wait and see approach: they used time. Clearly, the particular approach chosen will vary according to the personality of the doctor, and in particular their tolerance of uncertainty/propensity to take risks. We did not attempt to make any assessment of these variables in our study but they have been discussed by other investigators.10
The Doctor's Knowledge and Experience There are two aspects of the doctor's knowledge and experience we've found to be influential in referral decision making: having particular knowledge or
DISCUSSION The findings reported here lend empirical support to discussions of referral such as those by Aulbers" which identify the range of possible influences but do not themselves collect and analyse data to demonstrate the validity of their conceptual schemes. We have seen, therefore, that referral decisions are influenced by four groups of factors (Table 1). Since many of these factors have little to do with doctors' reasoning processes we are led to suggest that an approach such as the one adopted here represents a useful complement to approaches which concentrate on the purely cognitive aspects of referral decision making. We would agree with Dowie and Elstein who have said that "clinical decisions are not isolated cognitive events." 12 In other words, decisions about the referral of patients should be seen as integral to the context in which the decision maker operates. This context might be described as 'the environment of decision making'. 13 In large part this environment consists of a number of interacting components which form an active and conscious part
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The Doctor's Relationship with Consultants Most of the doctors we interviewed knew the consultants to whom they referred. They felt that this could influence their decision making about cases which fell into the 'not sure' category in three ways: firstly, it could facilitate an informal contact. That is, it meant that a doctor could telephone a consultant to obtain an opinion about the appropriateness of referring a problematic case: " . . . often you might get in ophthalmology conditions in which an acute red eye is not responding to straightforward antibiotic therapy and you may think that they've got an iritis for example. But by and large, what you might do on that occasion is phone the ophthalmologist on call that day and discuss that with him." (Interview no. 7) Secondly, it enabled doctors to know what consultants expect. When a doctor has referred patients on previous occasions and has thereby come to know how the consultant has responded, s/he can assess, for example, whether an early referral of a patient whose problem is not straightforward would be appropriate. Thirdly, it protected the doctor's self esteem. At many points doctors told us that they were concerned about how referral reflected on them as practitioners. They were mindful, for example, of not wasting consultants' time, or felt guilty about referring patients who they might well have continued to manage themselves. Knowing a consultant, it was argued, meant that a certain kind of taken for grantedness could develop between the two parties—a doctor could refer a problem case knowing that the consultant would understand that there would be a good reason for the referral: " . . . I think if they know you vaguely and they know the types of things you refer, they know that you are not going to refer rubbish in that you do have a reason behind referring somebody and you are not just sending everybody that you have in the surgery just for the sake of it." (Interview no. 8)
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interests in a medical specialism; and learning from experience. Doctors often said that they had particular interests within the field of general practice and different levels of knowledge. Generally, where a doctor mentioned a speciality (e.g. eyes, skins, etc.), this was thought to reduce the rate of referring in that area. In explaining this relationship the most frequently cited factor was that of confidence: "If you've worked in an eye department for two or three years you are going to be pretty confident in that area." (Interview no. 12) "If you're interested in a field, hopefully you've probably got more confidence so you can actually deal with them better . . . er . . . without the need for a consultant's opinion." (Interview no. 5) The same doctor, however, inserted the following proviso: " . . . as you deal with a field in particular, sometimes you attract . . . er . . . people within the practice to come and see you for that particular speciality . . . um, for that reason you probably have to refer a few more o n . " (Interview no. 5) The second aspect concerns knowledge gained through experience. Many of the doctors interviewed said that they referred fewer patients now than they did when they first qualified. The typical explanation ran as follows: "I think its increase in experience and having seen something before and having had a consultant opinion about it in the past." (Interview no. 8) "As time goes by you mature a little and learn what does require referral and when." (Interview no. 7) This learning process did not always occur naturally. Some doctors saw referral as being in part an educational process: "I think it is an absolutely legitimate part of the health service to use a consultant to learn from. So if you're a trainee or a young principal, and you're not sure about a condition or a rash or something then its legitimate to send that patient up to see a consultant." (Interview no. 2)
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FAMILY PRACTICE—AN INTERNATIONAL JOURNAL TABLE 1
Factors influencing general practitioner's referral decisions REFEFSWL DECISIONS
Factors
Krudural Factore
PHlanlAstodalad Factora
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2 Doctors'corapfan of c m
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5 PflMpliiin
CONCLUSION Since referral to secondary care results in the consumption of scarce resources health services managers and policy makers have been keen for recorded variations in referral rates to be explained. Such explanations might then serve as the basis of policies designed to exercise more control over referral. The findings of this study suggest that we are far from being able to explain
Owl
5 CorauBilon irnt
patterns of referral and that a perspective which begins by attempting to understand the meanings and motives of those involved in the process of referral may be more fruitful than the positivist paradigm which has influenced much of the research in this field. The indications are that a large number of referral decisions are not only difficult to make from a clinical point of view but are also further complicated by the personal values, skills, and experiences of those involved as well as the nature of relationships between them. ACKNOWLEDGEMENTS We would like to express our thanks to the fifteen general practitioners who took part in the study; to the Northumberland LMC for their support; to the Primary Health Care Development Fund for funding the study; and to the Department of Health for supporting Dr Hutchinson. 1
2
3
4
REFERENCES Storey CJH. A hospital outpatients study. J R Coll Gen Pract 1961; 4: 214-222. Morrell DC, Gage HG, Robinson A. RefeiTal to hospital by general practitioners. J R Coll Pract 1971; 21: 77-85. Coulter A, Noone A, Goldacre M. General practitioners' referrals to specialist outpatients clinics. Br Med J 1989; 299: 304-308. Dowie R. General practitioners and consultants—a study of outpatient referrals. London, King Edward's Hospital Fund for London 1983.
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of the doctor's decision making. An important interaction has been identified between clinical and nonclinical aspects of presenting problems. Having identified these factors we would not hypothesize that any of them would operate to increase or decrease referral decisions in a uniform or predictable way. Thus, a good doctor-patient relationship might facilitate openness in communications and help doctors reassure patients in cases where the doctor does not think that a referral is necessary. The same good relationship may also encourage patients to be less inhibited in making a request for referral in the first place. Similarly, where doctors possess some specialist knowledge this could reduce the number of referrals they make to consultants in that speciality because they know what can be done for patients and what is available. At the same time where less knowledgeable partners are aware of a colleague's specialist interests this may prompt them to steer patients in that colleague's direction, and a proportion of these patients may then be referred.
Cowrt
GP REFERRAL DECISIONS 3
6
7
8
Wilkin D, Smith A. Explaining variations in general practitioner referrals to hospital. Family Practice 1987; 4: 160-169. Glaser B, Strauss A. The Discovery of Grounded Theory. Chicago, Aldine, 1967. Schwartz H, Jacobs J. Qualitative sociology: A method to the madness. New York, Free Press, 1979; 289. Aulbers BJM. Factors influencing referrals by General Practitioners to Consultants. In Sheldon M, Brooke J, Rector A, (eds). Decision making in general practice. London: MacMillan 1985.
9
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11 12 13
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Eddy DM, Variations in physician practice. The role of uncertainty. In Dowie J, Elstein A. Professional Judgement—A Reader in Clinical Decision Making, Cambridge, Cambridge University Press; p 2. Cummins RO, Jarman B, White PM. Do general practitioners have different "referral thresholds?" BrMedJ 1981; 282: 1037-1039. Aulbers BJM, op. cit. Dowie J, Elstein A. op cit. Introduction, p 27. Cook S, Slack N. Making management decisions. London, Prentice Hall, 1984.
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