Navigating the Referral Process

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When your doctor sends you to another doctor

Pat Rich

Healer, counsellor, confidant: your family doctor plays many roles. But when it comes to diagnosing and treating complex medical problems, the most important role she or he often plays is that of a navigator of, and gatekeeper to, other parts of the health-care system. Originally, general practitioners did virtually everything. Even after the advent of surgeons and operating rooms, the typical GP of the 19th and early 20th centuries did procedures ranging from delivering babies to setting bones and performing minor surgery. Doctors with very specialized learning were rare and confined to university centres.

Photo: Masterfile

As medicine and medical care have become more complex, the time has long since passed when one doctor can be an expert in everything. More and more, providing health care is a team effort involving different physicians in very specialized fields.

The underlying principles of providing care in present-day Canada are based on the well-established British system, in which your family doctor, or in some cases a doctor in a walk-in clinic or an emergency room, will refer you to another physician who specializes in whatever your problem appears to be. This may be because the problem is complex or the original treatment prescribed by your family doctor is not working. It can also happen if special tests need to be ordered.

For example, when Ella, a 50-year-old Ottawa-based production artist, developed a suspicious lump in the front of her neck, her family doctor referred her to a laboratory to get specialized tests done. She then saw an endocrinologist specializing in the medical treatment of thyroid conditions. He recommended surgery to remove the mass. This meant another referral to a doctor specializing in thyroid surgery. After the operation, Ella was seen again by the medical specialist and her family doctor and was prescribed pills to provide the thyroid hormone she needed after part of her thyroid was removed.

“It took several months from the time my family doctor first recommended that I go in for tests until I actually had the operation,” Ella says. “Because I live in Ottawa but my family doctor and the endocrinologist and surgeon were in Toronto, the whole process of getting the tests done in labs in Ottawa and setting up appointments with doctors seemed complicated. But in the end it was worth it.”

Joanne, 60, a Toronto writer, similarly found how difficult it can be to navigate the health-care system. A stubborn sinus infection involved visits to two family doctors, an ear, nose and throat specialist and a dentist, as well as an X-ray, a CT scan, two months of antibiotics and finally sinus surgery and a tooth extraction.

“It took nine months from start to finish and was a very frustrating experience,” she says.

In Canada it can be difficult, if not impossible, to see a specialist without a referral from a primary-care physician. In the U.S., however, you can book an appointment with a specialist directly. A primary-care or specialist referral to a subspecialist has usually been the case in Canada since medicare was phased in during the late 1960s, and today’s shortages in some medical specialties it has become even more the rule. The aim is to ensure that specialists’ time is used most effectively.

The organizations that represent Canadian doctors acknowledge how complex and time-consuming the system can be and are constantly working to improve the referral and consultation process. The advent of electronic medical records and systems that digitally store test results can make it much easier to ensure that health-care providers receive all the information they need.

Another important function family doctors have is in properly preparing patients before they’re referred for specialty care. “It’s part of our role to make sure our patients are well informed and understand the nature of the referral,” says Dr. Louise Nasmith, a Vancouver family doctor and former president of the College of Family Physicians of Canada.

Patients, however, also have a duty to prepare themselves and become advocates for their own care. “It’s important for the patient to be a full partner in this referral process,” says Nasmith. “I will personally tell patients, ‘When you go, these are the sorts of questions you need to pose in addition to what I’ve written here. Because you need these answers.’”

Dr. Luis Oppenheimer, who, as Manitoba’s director of patient access, is involved in a multi-million-dollar pilot project to improve access to medical care and reduce waiting times, agrees: “It’s a good idea for a family doctor to inform patients as to what they should ask and to interpret the responses for patients.” Adds Dr. Steve Pelletier, a family doctor in Rockland, Ont., “I try to prep patients by letting them know that I will be sending all pertinent information to the specialist.” Pelletier does his part to get the specialist consultation off on the right foot by providing a complete list of therapies tried and investigations undertaken, as well as comprehensive summaries of patients’ health and any medications they are taking.

The gorilla in the room is often the wait times patients will face before they see their specialists. Here as well the family doctor can help. “Patients need to be properly informed about the expected waiting times and they need to be provided with advice about the alternatives available to them if the wait time is unreasonable,” adds Dr. Jack Burak, a Vancouver family physician and deputy registrar of British Columbia’s physician licensing body.

Specialists, too, have com­muni­cation duties. Most provincial ­licensing bodies for doctors state that consulting specialists have an obligation to report back to the ­family doctor on the outcome of the visit, so the family doctor can ­continue to provide ongoing care and plan the next steps in treatment.

The roles and responsibilities of the doctor referring a patient to another physician for consultation and the physician providing the consultation are well defined by many licensing bodies as well as the College of Family Physicians of Canada and the Royal College of Physicians and Surgeons of Canada. So, too, are the expectations of what you, the patient, should be doing to ensure this process works well.

Patients are not necessarily alone in all of this. In the case of cancer patients facing long and complex treatments, having a non-physician specifically dedicated to helping them negotiate the system can keep them informed about the treatment process and ease the burden on their physicians. A unique program established by Cancer Care Nova Scotia in 2001 provides navigators who work with cancer patients and their families and physicians to get patients the information and services they need.

“Having someone who can be reached at a toll-free number and is easily accessible and who understands cancer and is also connected in the system and has access to ­patients’ records can help them understand what their physicians have told them,” explains Sandra Cook, the program manager.

Nancy Roach, a patient navigator in the Annapolis Valley region of Nova Scotia, agrees that despite the best efforts of physicians, cancer patients often don’t understand what’s happening. “For example, I just got off the phone with an advanced prostate cancer patient who has to go on hormone therapy and have radiation post-prostatectomy,” she says. “I was explaining what the urologist meant about treatment side effects such as erectile dysfunction.”

In the absence of such a patient navigator, it’s up to referred patients to make sure they’re as well prepared as possible. Never feel guilty about asking your referring doctor about what to expect from tests or specialists and what happens next. After all, it’s your health, and doctors — whether family physicians or specialists — are there to help you maintain it.