I know things are busy right now. We are stressed, and not the kind of stress that lunch-hour chair yoga fixes. Stress shows up in small ways — like a grocery cart left in a parking lot instead of being returned to the corral. It's not laziness, it's bandwidth. But it also means the next person has a little more work to do.
The same thing happens with referrals. A referral that's missing a few key pieces doesn't save anyone time — it just shifts the work downstream, usually to clinical support staff and, eventually, to me.
I've been a pain management physician assistant for almost two decades, and I’ve seen what it looks like when a referral lands poorly. Here's a short refresher on how to ensure your pain management referrals — or any referrals, for that matter — land as intended.
Document something. If a note recommends a pain management referral but doesn't describe the pain anywhere in the visit, the referral is incomplete before it even arrives. Everyone downstream — support staff, me, the patient — is working from that note. It needs to carry the information. A systematic scoping review of 54 studies identified complete medical history, relevant investigations, and physical examination findings as the foundational elements of a quality referral. Without them, the referral is missing its clinical backbone.
Be specific. If you're diagnosing a chronic painful condition that warrants a specialist, put it on the active problem list. "Other chronic pain" doesn't give me or anyone else enough to work with. That same review found that clear referral indication and clinical reasoning — not just a diagnosis code — are what distinguish a useful referral from one that creates more questions than it answers. In the VA system, use of referral templates was associated with significantly improved referral appropriateness, clarity, and completeness. Even a brief structured format helps.
A patient request alone isn't a referral. If a patient asks to be referred, that's worth exploring — but a request passed along secondhand through a patient services representative, without a workup behind it, often comes back to me without enough substance to act on.
Do a basic workup first. Going straight from "back pain for three months" to "refer to pain management" skips steps that could genuinely help: lifestyle changes, medication trials, referrals to noninvasive modalities. Not every symptom needs a specialist, and patients don't want an endless string of appointments.
Think of pain management as the last stop, not the first. The stepped care model, endorsed by the HHS and the Veterans Health Administration, explicitly advocates beginning with the least resource-intensive services — self-care, exercise, weight management, medication trials — and progressing to specialty care only when these are insufficient.
The ESCAPE trial, a randomized clinical trial in veterans with chronic musculoskeletal pain, demonstrated that a stepped-care intervention (analgesic optimization plus self-management, followed by cognitive behavioral therapy) produced significantly greater reductions in pain-related disability and pain severity compared to usual care, with benefits sustained over nine months.
Clinical practice guidelines recommend specialist referral specifically when nonspecialist management is failing, chronic pain is poorly controlled, or there is significant distress — not as a first-line response to a symptom.
Bring in outside records, especially anything related to the referral diagnosis. Reconciling the EMR active Problem List (something Epic makes simple) directly saves everyone time — in my case, time I'd rather spend with your patient.
Explain the medication you've started, even briefly — what it's for, roughly how it works. If a patient tells me they don't know why they're taking something, that's a gap in their care I have to fill in on the spot.
Tell patients why they're being referred. "I don't know why I'm here" is something I hear constantly, and some patients read it as being brushed off. Even a simple line helps: "Specialists have more time and more tools for this." Setting expectations up front makes the visit land better. A qualitative study of patients who failed to complete recommended referrals found that patients desired clear communication about the referral's rationale and value, and that failure to provide this — especially when combined with system friction — significantly contributed to referral non-completion.
In another study, 85% of patients received a good explanation about the reason for referral, yet 26% still felt unprepared about what to expect; trust in the referring physician was highly associated with the quality of preparatory information received. In head and neck cancer referrals, clinicians who overlooked explaining the referral left patients unaware they had even been referred, causing delays and confusion. Pain referrals are no different.
Be careful with language around imaging. Terms like "degenerative disc disease," "bulging discs," or "nerve damage" carry weight patients often can't fully contextualize. Pointing at a scan to validate someone's pain can unintentionally reinforce fear and catastrophizing — imaging doesn't show pain, and words shape how patients relate to their own bodies going forward.
The evidence here is striking: degenerative changes on MRI are found in 74.4% of people without low back pain, with prevalence exceeding 90% in those over age 69. A cross-sectional survey across five countries found that 59%-71% of patients considered common and usually non-serious imaging terms (disc bulge, disc degeneration, spondylosis) to indicate a "serious back problem," and 42%-57% reported they would be fearful of movement based on these terms alone. Fear-avoidance beliefs are directly linked to worse outcomes: a meta-analysis of more than 15,000 patients with chronic musculoskeletal pain found that higher levels of fear-of-pain and fear-avoidance beliefs were significantly associated with greater pain and disability. A patient's knowledge of imaging abnormalities can decrease self-perception of health and may lead to fear-avoidance and catastrophizing behaviors that predispose people to chronicity. The words we choose matter as much as the scan itself.
Have an exit plan before starting treatment. Providing medication to "bridge" a patient to their pain management appointment, without a clear stopping point, can create real confusion about what the standard of care looks like. On my end, decisions are grounded in evidence and standardized risk assessment. The U.S. HHS best practices document emphasizes that a treatment plan should include establishing a diagnosis and measurable outcomes focused on quality of life improvements — not open-ended prescriptions without a defined trajectory.
Help patients feel some agency. Outcomes tend to be worse when patients feel like passive recipients of care with no control. Something as simple as "I think you're going to feel better, and this doesn't have to define you" goes a long way. Patients need to hear there's a path forward, not a dead end. A meta-analysis of 86 samples (N = 15,616) found that self-efficacy had significant negative correlations with pain severity, functional impairment, and affective distress in chronic pain populations, and prospective studies confirmed that baseline self-efficacy predicted subsequent functioning even after controlling for baseline outcomes. Fostering a sense of agency isn't soft encouragement — it's an evidence-based intervention.
Heeding these steps can go a long way toward improving trust with patients and between colleagues. The better we communicate, the better this works for our patients, and the less friction for both of us.
