I still remember the first referral letter I wrote as a GP registrar as if it was yesterday. It was for a 20-year-old with an acute abdomen, who I sent in on my first night on call. I was devastated when my trainer thought it was a little wordy and suggested a more pertinent form of words. But I learnt that there are crucial elements to a referral letter.
How best to write a referral letter
- Be clear and concise, especially with emergency referrals.
- Make sure you tailor the letter to the person who will read it. More junior members of staff might need more explanation than specialists.
- Explain why the referral is needed functionally and describe any relevant social circumstances. Use print-outs to detail history and investigations and highlight relevant information.
- If you are unclear of the diagnosis, tell the specialist what you want from them, providing your differential diagnoses. Do not be afraid to admit your ignorance.
- Advise on the patient’s ideas, concerns and expectations of a hospital appointment and explain if there may be involvement of stress or anxiety in the patient’s condition.
- Writing referral letters well requires practice. Consult your colleagues and take time to learn the art.
Who to refer to
Consider first to whom you are referring. Most referrals are to outpatient clinics and generally, I do not mind which specialist within a department I refer to and by generically referring to any consultant within a department I hope my patient gets on to the shortest waiting list.
However, you may need to refer to a particular consultant who has a specialised interest in a particular area, or perhaps the patient seen a particular consultant previously and would like to see them again. More importantly, there may be a particular consultant you want your patient to avoid and therefore you need to select a specific one to circumvent this problem.
What should be in the letter?
For a simple referral, one or two lines may be adequate to describe the problem. Explain why the procedure requested is needed functionally. Describe any social circumstances relevant to the patient’s discharge or rehabilitation.
Use print-outs from the clinical system to detail areas such as medication, relevant past medical history and previous investigations and use highlighters to mark out important detail within long print-out reports.
In complicated referrals where you are unclear of the diagnosis think clearly about what to say. State what you want from the specialist in the first paragraph before going into the detailed chronology of history or examination. Try to highlight the key points or events in a history rather than listing endless negative findings. Summarise your thought processes with your differential diagnoses.
Do not be afraid to display ignorance when asking for help within a referral. If you are baffled by a problem the specialist may also be. Stating why a problem is important in functional or social terms may be more valuable to a specialist than your lack of specialist knowledge.
Advising on a patient’s concerns and expectations of a hospital appointment may be vital if the hospital is being asked to provide a second opinion to confirm a diagnosis. Equally, recognising the role of stress or anxiety within a patient’s presentation may be helpful for a specialist in understanding the patient’s problem.
To me, emergency referrals are significantly different. Firstly, I need to write or type them, rather than dictate them for a secretary to deal with, which makes them short and to the point.
Secondly, they are always read but often only by the most junior member of the team. This makes the need to highlight key medical, drug and social history essential.
Referral to alternative practitioners
Referrals to paramedical or alternative practitioners outside the NHS might need to be made to meet the need of a third party, such as a private insurer.
Sometimes patients ask for or insist on these referrals even when you feel they may be of little value or they may ask for referral to forms of alternative care about which you are, at best, ill informed. In such circumstances I often simply provide a print-out of a patient’s key history by means of background information.
Express yourself clearly
Finally, remember when you refer a patient, in some way you are supporting or endorsing a particular course of action. If you are forced to make a referral that you do not support fully or even partially or you are asked to refer to someone you do not know, do not feel inhibited to express this in your letter.
Expressions such as: ‘Please see this patient who requests your opinion on…’ are entirely reasonable.
Referring a patient on for further care is often a complicated decision reached after much thought and deliberation between doctor and patient. Learning to express this process succinctly while highlighting key information in a concise form is a skill that takes time and practice. Use your time as a registrar to acquire the skill. Consult trainers, colleagues and practice secretaries to learn the art.
Dr Wagman is a GP trainer in Edgware, greater London