Family medicine as a specialty has always been the proverbial “jack of all trades.” Family physicians deal with diseases of every single organ system and patients of every demographic. This comprehensive approach to caring for the vast majority of patients and disease processes is one of family medicine’s most attractive qualities, and helps it stand out from all other specialties. However, this celebrated comprehensiveness is presently becoming eroded in the face of a culture of referring out.
More and more over the years, I have had patients and personal acquaintances make comments to the effect of “PCPs just give you a referral, they don’t actually solve any problems.” While this is clearly hyperbole, I do feel there are often patients who would like to receive more care from their primary and who are sometimes met with a referral elsewhere instead of an attempt at treatment. Regardless of whether unnecessary referrals are more than mere anecdotes, the perception of primary care physicians doing less by patients is an issue. Additionally, there are several system-level pressures that could frankly encourage unnecessary referrals.
In the fee-for-service realm of health care, the answer to higher costs and decreased payments is volume. (Of course productivity and efficiency enhancements are helpful to some degree, but more volume is often the main solution.) Practically speaking, only so many issues can be adequately and appropriately addressed in a finite period of time. Thus, when volume is pushed to the max, time constraints may tempt primary care physicians to not manage conditions that they could otherwise easily and safely address. A last-minute skin concern at the end of a long visit is likely easier dealt with by an “I’ll refer you to dermatology” than by taking extra time or asking the patient to return for a dedicated visit for that problem. But just because it’s easy doesn’t mean it’s right. In an environment where physician Medicare payments continue to decrease and inflation has made everything, including health care, more expensive, it’s easy to see how system-wide pushes and a lack of time could lead to the erosion of comprehensive care.
Another aspect of modern American health care that contributes to system-level constraints is the continued shift away from private practice ownership. Today, it is much more common for a physician to be employed by an organization, group, or health system than to own their own practice. In systems where physicians are less involved in decision-making processes, there is an increased chance that the changes implemented are solely to improve the bottom line, and are not for the benefit of the employees or our patients. Predictably, referral culture thrives in such a system, where “productivity” is paramount. (This is why, regardless of the system, it is incredibly important for physicians to be involved in leadership and management to ensure the clinical implications and constraints of certain changes are considered.) Often, trying to increase productivity can have negative impacts: whether it’s an increased number of referrals and subsequently longer wait times to see specialists, a degradation of the quality of care provided, or increased physician burnout, the downstream effects of focusing too much on productivity can be significant.
Taken together, all of these issues may tempt the primary care physician to refer out more often than necessary so as to save time, allow for more volume, or otherwise deal with the repercussions of a health care environment that is increasingly difficult to succeed in. And yet, this approach has consequences. On a personal level, our work is more rewarding when our perceived impact is greater. If we simply become a middle man to another physician for every health care issue, physician satisfaction and morale will certainly decrease further, and it’s possible the satisfaction of our patients will as well. Further, the less we do as family physicians, the more we narrow our scope and harm the future of the specialty by potentially creating a new norm that excludes us from managing certain conditions or acuities of illness. In addition, unnecessary referrals lead to longer waits for specialists’ appointments, which in turn negatively impacts those patients who truly need specialist care the most. Not to mention, it drives up the health care costs as a whole for systems, insurers, and patients themselves.
Of course, referrals are a necessary part of health care when used correctly. Collaboration among physicians of different specialities is essential for quality patient care. However, it is the routine use of referrals without an appropriate indication and/or initial workup that is damaging to all involved.
To keep family medicine true to its heart, there are several things we can do. First, we can resist the myriad pressures working upon us by speaking openly and honestly about such pressures. Second, we can ensure that we are consistently performing a variety of procedures within our scope, even when time constraints would make it easier to defer to someone else. Third, we can strive to stay up-to-date on new research, updated guidelines, and potential new medications or indications by browsing health care news bulletins and reading journals regularly. By keeping our scope broad and treating patients appropriately while safely maintaining the standard of care, family medicine physicians can improve our own morale, the future of the specialty, and the overall state of the American health care system.
How often do you find yourself referring out? Are you satisfied with this approach, or looking to change it? Share in the comments!
Dr. Del Carter is a family medicine resident physician in Tallahassee, FL. He enjoys traveling, watching sports, working on cars, and spending time with friends and family. Dr. Carter is a 2024–2025 Doximity Op-Med Fellow.
Animation by Jennifer Bogartz
