When patients request referrals – an analysis of individual interviews with general practitioners

Current data from a cross-sectional study of referral patients from 29 general practitioner practices in Germany suggest that around a quarter of referrals take place at the request or request of the patient [1]. Information about such transfers in Germany is mainly based on opinion pieces and experience reports. There are numerous hits on the topic in the open Internet search service Google, especially in health-related public publications and general medical publications (“medical tribune”, “Ärztezeitung”, etc.). Referrals are sometimes issued after this without any doctor-patient contact having taken place [2-3]. Such referrals can lead to oversupply and thus endanger patient safety and strain medical and solidarity-funded resources. Due to the sparse scientific data for the German care system, the aim of this work was to collect experiences and opinions from general practitioners in the context of the active demand from patients explore transfer.

>> This analysis of the text material from the interviews supported by 22 key questions relates to the topic of “doctor-patient contact” with a focus on “the patient’s active request for a referral”. (The question in the key questionnaire was: “How do you deal with the situation when patients actively request a referral?”). Statements with the term “request transfers” or “transfers on request” were also taken into account. Results of this study on the topic of “doctor-specialist contact” have already been published elsewhere [6].
Results
Three main categories with respective subcategories were formed from the text material (see Table 3).
The main categories (identified as headings in the body text) and their subcategories are detailed below:

Quantitative assessments
The majority of all referrals would be made at the registration desk at the patient's request. Information on the proportion of referrals that take place at the patient's request is 30 and 70%;

reasons
Media (e.g. television or internet) or the social environment (e.g. neighbors), the family doctor contract and the preference of the specialist (e.g. dermatologist, urologist, orthopedist) were cited as reasons for requests for referrals. Some interviewees expressed that referrals that patients request or request are initiated by specialists for economic reasons.

Handling
A number of behaviors were identified. This includes, for example, different documentation within the practice or the doctor's (not) sharing of findings when a referral is requested, refusing requested referrals, explaining (in the sense of explaining) or questioning the doctor about the necessity of such referrals and agreeing with comprehensibility. Some doctors reported that they would comply with the request or request for a referral for “legal reasons” or “lack of time.” Transfers on request would also be issued to avoid negative consequences; The “scaring away” of patients if they were not referred was explicitly mentioned. For detailed information see Table 4.
discussion
The results of this study suggest that referral requests are a relevant phenomenon at the interface between general practitioners and regional physicians. It becomes clear that the topic has many facets. The three main categories will be discussed below.

Quantitative information
“The majority of referrals” would be displayed outside the treatment room (at the patient’s request). In 2004, the practice fee was introduced as part of the Health Modernization Act (GMG) and has since been abolished. In order to avoid having to pay another 10 euros to the specialist, patients needed a referral from their family doctor. The effects of the introduction of the practice fee on the frequency of referrals were examined in Dahmen's doctoral work in general practitioner practices in North Rhine-Westphalia: after the introduction of the practice fee, patients requested referrals from their family doctor more frequently [7]. It is unclear whether these mostly took place in front of the treatment room. It is not clear from the available data what significance “in the main percentage of referrals” routine referrals represent and whether the medical assistant consults with the doctor regarding these patients.
The general practitioners' assessments of the frequency (see Table 4) of required referrals are considerable and quite realistic. Bösner et al. assume, based on the results of the cross-sectional survey cited in the introduction, in 29 German general practices that around 70% of all referrals are (co-)initiated by patients [8]. It also remains unclear whether referrals at registration, which are discussed in the present results, are requested solely by the patient, whether there is/is no assessment of the medical facts by the doctor or whether they are issued in the absence of an indication.
In the cross-sectional survey by Rosemann et al. On the topic of “referral from family doctor to specialist,” the referrals from 26 German family doctors were reviewed. In around 5% of the “direct referrals” (i.e. referrals in which a personal consultation took place), the general practitioners were of the opinion that they were “actually against the referral” [8]. In the cross-sectional study by Schneider et al. In 13 German general practitioner practices, “patients with counter referrals” (n=307) did not differ from patients from consultation hours (n=977) with regard to mental illnesses (depression, anxiety and panic disorder, somatoform disorder) [9].

reasons
A number of reasons that lead to demands for transfers could be detected. The influence of media is plausible and corresponds to the experiences of the practicing author; it is also mentioned in individual interviews with family doctors on the topic of “family doctor image in social change” [10]: Younger patients in particular who are familiar with the Internet obtain information about their illnesses or symptoms. The point mentioned by the doctors interviewed about the influence of their social environment (e.g. neighbors) is also understandable.
With the mention of HZV (family doctor-centered care), a “system-related” reason was addressed. This is relevant because insured people participating in the HZV are only allowed to see a local doctor with a referral from their family doctor. Another mechanism for controlling transfers in Germany is through structured treatment programs (Disease Management Programs, DMP).
It is clear from the material presented here that patients prefer specialists, in this case urologists, even for trivial illnesses such as uncomplicated urinary tract infections. Some patients probably generally underestimate the skills of a family doctor. This assumption and the above facts (the top priority of the diagnosis by the specialist) are reflected in the statement that “it has to be the orthopedist” who is preferred for musculoskeletal complaints. The referrals to the orthopedist seem relevant because at least 35% of all patients visit the orthopedist with a referral from their family doctor [11].
Family doctors would also be confronted with referrals requested by area doctors. The individual opinions on this imply possible business reasons and a lack of medical indication.

Handling
The many subcategories for handling show that family doctors (have to) deal with the respective patients in a differentiated manner.
A survey of 160 British general practitioners more than 20 years ago made it clear what consequences issuing referrals can have if the patient insists: This showed that the total number of referrals is increasing and that a higher referral rate (in relation to the total consultations in a practice in a defined period of time) was associated with those general practitioners who reported greater “pressure from the patient” regarding a referral [12].
Dealing with requests for referrals also includes refusal/rejection and questioning as well as explaining to the family doctor whether it is unnecessary. Understandably, such discussions with patients in everyday practice do not always seem to be able to be carried out by family doctors due to time constraints.
Behind the “consent for legal reasons” is probably the family doctor’s reassurance or fear that in (rare) cases a referral might be indicated. Unfortunately, no further information about this could be gleaned from the interview.
The provision of findings (including medication plans) and the definition of the clinical question by family doctors are essential for problem- and patient-oriented treatment. In this context, specialists complain that referred patients are often inadequately provided with such information [13-16]. According to the data available here, the inadequate reporting of findings appears to occur particularly in the context of requests for transfers.
We think that the “fear of alienating patients” if not referred correlates with referrals that are not medically indicated.
In a statement or statement of position by Australian authors on the topic of the referral process from the family doctor to the specialist, obtaining an opinion from the specialist is the top priority for patients when making a diagnosis. In addition, the (generous) issuing of referrals to specialists should be understood as part of joint care by both groups of doctors and brings about an improvement in the doctor-patient relationship [17].

Strengths and weaknesses
The present study is the first study to attempt to qualitatively examine requests for referrals from GP patients. It was carried out in several regions (of Baden-Württemberg) by an interdisciplinary team and was designed to describe the phenomenon on a broad basis. The heterogeneity of the surveyed collective ensures the necessary structural variation to elicit the broadest possible spectrum of opinions.
One limitation is that the reasons for non-participation of the practices in the Heidelberg and Ludwigsburg region were not recorded. A control for potential selection bias could therefore not take place. The focus of this study was the survey of general practitioners; Although requests for referrals from specialists can also be expected, the information collected here is not easily transferable to other areas of outpatient (and inpatient) care.
conclusion
The data makes it clear that family doctors (have to) deal with the respective patients in a differentiated manner when making referral requests. Requests for referrals appear to be (co-)initiated by the doctor on a case-by-case basis. The distinction from referrals within the scope of indicated check-ups appears difficult. Transfer requests take place in or in front of the treatment room. In the latter case, it remains unclear to what extent they go hand in hand with and without a detailed assessment of the medical facts by the family doctor. Most of the statements from general practitioners presented here probably refer to patients in their consultation hours. Whether these statements differ from statements about patients who request referrals in front of the treatment room (and receive them there) remains an open question. <<