Making an Inpatient Specialist Referral
Making a call to another specialty to request an inpatient consultation can be very frightening at the beginning of your career. You want to perform well, but you know that there could be some tricky questions that have the potential to make you feel embarrassed and walk away without having achieved your team's objective. From the specialist's point of view, he (or she) is likely to be very busy and you will have interrupted him, so he isn't likely to tolerate anything other than short, sharp and to the point. So here's a few tips on how to go from long-winded, waffly and inefficient, to a referral that is "quick 'n' slick".
1. Be clear about why you are referring the patient
The most important thing to be clear about is why you want another specialist's input. For example, you may have a patient with a dangerously low white cell count and a haematologist might help to establish the cause and recommend a treatment plan. Or you may have a septic patient and you need an intensive care specialist to consider inotropic support and a transfer to the Intensive Care Unit. Whatever the reason, make sure you understand precisely what this reason is. If you're not sure, then just ask.
2. Understand your patient's history
Open up the patient's medical records and be ready to give the following summary:
current status - is the patient acutely unwell or stable?
admission history - this will include the date of admission, and important developments;
past medical history - information about comorbidities helps the specialist build a mental picture over the telephone of the kind of patient you are caring for.
You will note that the above history is not the same as the kind of history you will take when you see a patient for the first time. When making a referral, your task is to deliver only the relevant information to justify your referral and help the specialist prioritise the patient review.
3. Gather supporting evidence
Sit down next to the telephone, and make sure you have all the information you might need to hand - you may not have thought of everything in your preparation, and it is unlikely that you will be able to remember the relevant details, such as yesterday's white cell count and the bicarbonate on the latest arterial blood gas. Here is a checklist of important information you should have to hand when making a telephone referral:
medical notes
nursing chart (detailing observations/vital sign measurements)
blood results
blood gas results
imaging reports
Much of this may be computerised - load it up before making the phone call. It can be quite frustrating as a specialist to hear "hang on a minute, I'll just go and get it", followed by two minutes of silence! So have it all ready and then make the call.
4. Communicate
Think about what you are going to say before you say it, and then be systematic. Here is an example of a system to help you communicate effectively and efficiently when making an inpatient specialist referral:
A) Introduction
B) Purpose
C) Patient history
D) Time frame & Tasks
Let's take these four points step-by-step.
A) Introduction. It seems really obvious, but don't forget to introduce yourself! A specialist receiving a referral would like to know if you are a doctor or a nurse, and your name so that he or she knows who to call to feed back about your patient. B) Purpose. The next thing the specialist will want to know very quickly, is why you are calling. It helps the specialist to put everything else he or she is about to hear into context, to be able to consider the details within the right 'frame'. For example "Hi, I'm Joe Bloggs, the FY1 doctor on the renal team calling from ward 1 and I would like you to come and review a patient who we found to have a suspicious pulmonary nodule". Immediately, the specialist knows what he or she is dealing with, and can think about the subsequent details in the context of a patient who has a pulmonary nodule.
C) Patient history. Summarise the patient history. You may lead into this with "let me tell you a little more about the patient". Provide the name, hospital identification number, date of birth, and location, and then present the history as laid out in part 2, above. Include significant comorbidities at the start of this section - remember, context is important. So, in our above example of a patient with a pulmonary nodule, then it becomes very relevant if he also has a 60 pack year history and COPD.
D) Time frame & Tasks. Ask for an idea about when to expect the patient review to occur, or make it clear how urgent the review is (and be prepared to justify this). Finally, ask if there is anything the specialist would like to be arranged in the meantime. For example, a CT scan of the chest in our above example. Or in a patient with deranged liver function, an ultrasound scan would be useful.
Conclusion: anticipate
With time and experience, you will quickly be able to anticipate the questions you will be asked and information you will need when making an inpatient referral. This will speed things up and you will become more efficient as a result. To help you move to this point, here is a list of common referrals and what you should be thinking about when making a referral.
Do you have any tips for making/requesting inpatient referrals? Let us know your thoughts and experiences by commenting below.
