Tips for writing effective patient referral letters

By Wendy Glauser

This article reprinted with permission from the Medical Post. For free registered access to Medical Post online, go to www.CanadianHealthcareNetwork.ca.

Poor referral letters can reduce the quality of patient care, cause duplication of tests and waste specialists’ time—and that of GPs, if the cases are sent back with further inquires. Yet subpar referral letters are incredibly common, according to Dr. Wynand Wessels, an orthopedic surgeon in Grande Prairie, Alta.

"Only about one-third of referral letters are of good quality, meaning they have a decent clinical diagnosis, decent patient contact information and they describe what has been done for the patient," says Dr. Wessels.

While the needs of referrals obviously vary from specialist to specialist, using the following tips every time will be a great start to strong collaboration between you and referral specialists.

Provide accurate contact info
Before moving to a system whereby patients call to set up appointments, receptionists at Dr. Wessels’ office would often make more than 100 phone calls to patients just to fill 15 spots. In many cases, the patients had moved or changed numbers, says Dr. Wessels. To save both yourself and the specialist’s staff time, remind patients to update their contact information with reception when they leave an appointment and have them call if their phone number changes. In addition, make sure there is a systematic process in place in your office so when patients do change their contact details, specialists are notified.

Ask a specific question
There’s a reason medical school teaches that referral letters should include a clear question that the doctor hopes to have answered. Questions are more likely to be focused than statements. For example, "Please see re: diabetes," could inspire any number of tests and treatments, whereas "Would this patient benefit from adding drug X to their diabetes regimen?" makes it clear what the doctor would like the specialist to help with, says Dr. Erin Keely, chief of the division of endocrinology and metabolism at Ottawa Hospital.

In terms of how care is shared between the referring physician and the consultant, Dr. Keely notes, "The expectations of the amount of care the specialist will provide is very different among different physicians and in what works for individual patients." So specialists greatly appreciate it when the GP defines the specialist’s role as much as possible.

Remember that questions also help specialists decide on the urgency of the course. Dr. Wessels says he often has to prioritize non-urgent cases, at the expense of more important cases, due to a lack of information.

"If the letter says, ‘Patient has a painful knee,’ it could be anything, it could be cancer, it could be something mild, so where do we slot the patient in?" explains Dr. Wessels.

Include the necessary information
With EMR templates, it’s relatively quick and painless to draw up the information specialists need. While the requirements vary depending on the type of specialist, Dr. Wessels says he likes to see "what the clinical diagnosis is, what was done for the patient after the diagnosis was made and what exams were done."

Dr. Keely adds that letters should have space for medications the patient is taking, as well as relevant medications the patient has taken in the past. (Obviously, a medication list may not be necessary every time, such as with surgery referrals, but the list helps in cases for which specialists might otherwise prescribe a medication that has already failed.)

Where possible, says Dr. Keely, the letter should indicate what exact clinic the doctor is requesting. "I work with a group of 12 endocrinologists with different focuses, from bone and stone disease to diabetes to thyroid problems," she explains. Given that template letters are laid out with clear headlines, don’t be afraid to err on the side of more information. "I don’t mind more information than I need as long as there are headings," says Dr. Keely. "It’s easy to scan through to get to the information you’re looking for."

Denote ‘second opinion’ cases
If it was the patient who requested the specialist appointment, specialists like to know this. "If they put in the note, ‘This person wanted a second opinion,’ we at least know this patient is not an urgent case," says Dr. Wessels. Dr. Keely adds that she may take time to reinforce the original physician’s message and "increase the patient’s confidence in the family physician" when she knows the patient requested the appointment.

Make the sense of urgency explicit
While the facts of a patient’s case can often speak for themselves, in many cases it’s still helpful for the doctor to state clearly if they think the case is urgent or routine, says Dr. Keely. In urgent cases, a note at the very top of the letter, such as "Urgent: next available" or "Please see this patient, condition deteriorating" can save medical staff time and ensure a timely booking.

Send lab reports
About 25% of referrals that Dr. Keely receives don’t include the necessary lab and X-ray reports. For many specialists, the words "X-ray normal" is not enough; they want to see the actual reports. In addition to helping with triaging, the reports tell specialists how long ago diagnostics were done. "There’s a date on them, and if there’s a six-month wait, the tests may need to be updated," says Dr. Keely.

Think of all potential readers
With every referral letter, keep in mind that lawyers, other doctors, insurance companies and the patients themselves may end up reading it. To ensure against misinterpretations, upset feelings or other negative consequences, it’s important to write "as objectively as possible," says Dr. Keely. This means avoiding opining on another physician’s decisions and staying away from judgmental language when describing the patient’s history.
With the growth of e-platforms that let patients see firsthand medical communications, coupled with the idea of patients being empowered in their own health care, it’s becoming more and more common for patients to read the contents of referral letters.

Be mindful of specialists’ time
The imperative to provide the best care possible for patients can sometimes take over considerations of specialists’ time. Dr. Wessels says he sees "way too many people" who show up for their specialist appointment even though health interventions in the meantime cleared up the issue.

For example, knowing the wait is long, many family physicians schedule physiotherapy appointments or other such treatments that may solve the patients’ problem while they wait to see the specialist. If there’s a possibility that time will render a specialist appointment unnecessary, take the time to educate patients on the need to cancel specialist appointments or to see you if they’re not sure.