When to make a referral?

Referrals are a tough topic in primary care.

Two phone calls today reflect some of these issues:

"JMR .. patient on phone .. wants referral to a back doctor .. ok to make the referral?"

"uhh .. put her through please"

I want to talk with the patient so that I can understand why she wants the referral and why she thinks this is something that requires a specialist.  Clearly I am not a back doctor or a front doctor or a foot doctor ... but I may be able to help people with problems of these parts.  Turns out that the chiropractor hasn't helped much despite thrice-weekly treatments for 3 months.  She has low back pain.  No symptoms of anything bad.

What to do? 

• I can require that she come in to the office .. but then I am being the "gatekeeper."
• I can just refer her to the orthopoaedist .. but then I am making an inappropriate referral.
• I can refer her to physical therapy (which is what would most likely occur as a result of a visit with me or the orthopoaedist).
  
  Hmm ... which is the right answer?

Ok .. number two is harder.

I care for many physicians in my practice.   Caring for other physicians is tough.   Our office got a phone call a few weeks ago from a specialist about a referral that they needed from us so that they could see a patient who was there for an office visit that day.  The patient never called me .. never asked if I thought that a referral was necessary .. and never asked our office for a referral.  By making the appointment directly with the specialist - a message is sent to the primary care physician that our training and opinion is inferior to the patient's own ability to triage the situation.  For this scenario (I won't go into the details) I am certain that I would have been able to provide the service that the patient was looking for myself.    grrr...