Let’s have a word or two on referrals this month. Interprofessional referrals are such a key part of our practices. If done properly, they can help build our practices and certainly add to the quality of patient care. Most patients are naïve as to how the medical system works, and when they aren’t feeling well, they tend to be very appreciative if the proper direction is given. Most optometrists have a strong role in primary eye care, which fits nicely with the integration and collaboration of care that are current buzzwords.
How are YOUR referral skills?
A 59-year-old Asian female presents at 4:00 p.m. on a Friday afternoon with unilateral pain and blur o.s., worsening as the afternoon goes by. She is obviously “guarding” the eye, and she is in enough pain to be assisted in by her daughter. Ocular and systemic health histories are unremarkable. You find slightly reduced acuity in the affected eye, with significant redness and an IOP of 62. There is mild corneal edema and narrowed angles that are obvious by slit lamp exam.
So, the obvious question, “What WILL you do?”
Clinically, our glaucoma specialists encourage us to not make great attempts to stabilize the eye pressure in the office. Rather, if laser is immediately available, get the patient out and get it done. Practically speaking, it’s scenarios like this that can test our mettle. We’ve talked before about anticipation of failure, and emergencies outside our scope of practice have the same theme: preparedness. Have you talked to your glaucoma specialist, or at least your local general ophthalmologist, about how this patient might attain care? During hours? After hours? Do you have a narrow-angle glaucoma “kit” in case you can’t get the patient seen immediately?
How about sending patients to the ER?
On sending patients to the ER, the first rule of thumb is to not be bashful. The most borderline case will not seem trivial to the ER staff, compared to some of the problems that stroll in daily. (Our Air Force hospital ER fielded a mom who rushed in at 3 a.m. with a young child, and she demanded to see the doctor immediately for advice on brand and fit of baby shoes. Air Force regulations required that the “patient” be seen in a timely fashion.) If you have the slightest inclination that your patient may have an ailment that needs systemic monitoring or treatment, don’t hesitate.
How about those neuro cases?
The emergency room route may be the only way to have the patient see a neurologist acutely. Neurology office schedules seem impossible to crack. However, hospitals do maintain neurology call schedules. Note that your patient may not be seen quickly by the specialist, who may be relying on the ER staff to “stabilize” the patient and decide if the case should be kept in-house or turfed out to a university center.
A very viable option in many hospitals is to have the neuroradiologist assume care of patients who might otherwise see the neurologist. The neuroradiologist may be more available and has training in intervention in the serious cases that we send. My last two papilledema/idiopathic intracranial hypertension patients were seen, diagnosed, and treated appropriately by our hospital’s neuroradiologist. So, get to know your local neuroradiologist as an invaluable resource.
How do you present your potential diagnoses to the receiving doctor?
As a general rule, if I am asking for help, I present brief findings and a proposed diagnosis or two to the consultant. The specialist consultant will already have an intimate understanding of the scenario, so great detail is usually not indicated. Secondary diagnoses might best be listed as “…..but please rule out occult cause.” No, we’re not talking Devil Worship here, but simply conveying a healthy level of uncertainty as to the cause and effect of the patient’s illness. Save the extreme detail and speculation for another day.
One key point in ALL referrals is to explain what you expect will happen for the benefit of the patient.
Will the receiving doctor draw blood? Perform a physical exam? How about imaging in the form of x-rays, CT scans, or MRI? It’s also important to give your best ideas on the prognosis. Is this a grave situation, or will a few minutes with the specialist make things all better? I’m a big believer in taking care of the patient’s psychological well-being. Offering comfort as appropriate can go a long way.
As optometrists, we should be striving to be an integral part of the medical system. It’s the biggest source of professional satisfaction and advancement that I can name. Let’s sharpen our referral skills accordingly!