Thread by @drfjgarcia

I’m having some concerns about a behaviour I’ve been seeing in some receiving referral centres that is bothersome. I’m not sure it has a formal name, but I’m calling it #consultdiva . It needs to stop. What do I mean? See thread.

Def- #consultdiva : refusing consult requests by referring doctors claiming the referral is incomplete or deficient. Usually without any effort to correct those deficiencies themselves.

Let’s use some examples (I’m using a lot of Uro because hey…why not):
- GP: U/S shows renal mass
- Uro: incomplete referral, needs triphasic CT and re-refer.
-GP: please see for gross hematuria
- Uro: incomplete referral, need UA, triphasic CT, urine cytology then re-refer

-GP: please see for hydrocele
- Uro: incomplete referral, arrange U/S and re-refer.

There is so much wrong with this. To start, the consultant is holding the patient’s care hostage at the expense of the referring doctor’s time. A colleague has asked for your help and opinion, book the patient.

Quite frankly, it is in my opinion unethical to refuse to see a patient until your criteria are met. It’s a game of “guilt chicken” between more extra free work from the referring MD and the stubbornness of the consultant.

Who is going to be on the hook if there is a problem? The referring MD who cant find the time to meet the ever changing goal posts or the consultant who refuses to book until they are satisfied with the referral?

In a time where we discuss MD burnout/exhaustion, this is the worst possible way to treat our colleagues. The referring MD has identified a concern in your court – pick up the ball and run with it.

The message here is that the value of the time of the referring physician is worth less than that of the consultant. How would any consultant react if that is how they were treated? Terribly…

I’ve heard someone say “If they want their patient seen, they will get it done.” You might as well send this back with cut-out magazine letters, because you are holding the patient’s care ransom to make your colleagues do work for you.

“But the information will help me prioritize the referral” – but it doesn’t stop you from booking it. Use the info you have and make the best decision you can. If you’re missing something critical to decision-making, your admin can track it down.

Have your own admin call the pt and make the booking. Enough sending the date to the referring MD and expecting them to be the go between. You pay your admin for this, and if the pt can pick their date they will likely show up.

Referring MDs have enough other nonsense paperwork to do without consultant MDs using their office as a free appointment service. They also certainly do not need a 3 page document to fill out just to get care for their pt.

Once the appointment is made, I think its polite to send a copy of the date and time to the referring MDs. This confirms the referral has been received, and if the timing is too long, gives an opportunity for a phone call.

If the referral is incomplete, finish it. They are not specialists. E.g. hematuria referral without imaging - it should fall on me to arrange the imaging. I’m the one that needs it, not the referring MD

This reduces the likelihood the wrong test gets ordered, or a patient is given radiation unnecessarily. You know what you need and what will give you your answers, don’t treat referring MDs as free labour. #ChoosingWisely

If you think the referral is a waste of time, see the pt. Then in the note provide some helpful advice on how to identify the problem in question and rule out other more innocent pathologies. #EducateDontBerate

Clarification: the above is regarding office consults. I do believe that after-hours/emergency consults require more workup. However, if these are deficient, help them rule in/out what they need to get their answers. Don’t “nope” out.

I am always in awe with the amount of proverbial balls that generalists have to juggle, and quite frankly they have more “balls” than me. We need to work together and respect the foundation generalists provide for our system.

Truly, if we keep putting the #consultdiva/ivory towers higher and higher without supporting our foundation, the system will topple fast. Your colleague is asking for help…help them. From one specialist to the rest, lets end #consultdiva . Thank you for reading.