Referrals are an important part of the administrative structure of family medicine and specialist medicine. This mechanism streamlines the healthcare process and prevents overwhelming the specialist medicine department by enhancing the cooperation between primary care professionals (PCP) and medical specialists.
In most health maintenance organizations (HMOs) and Point of Service (POS), a referral from a PCP is required to see a gastroenterologist. Some gastroenterology clinics offer their services without the need for a referral. However, insurance companies might not cover the cost of visits to a gastroenterologist without a referral.
This article will explain the importance of referrals and detail the common referral process. It will then explain the specific requirements and processes involved for a referral to a gastroenterologist. Lastly, it will explain the process of development of referrals for gastroenterologists, narrowing down the symptoms for urgent referrals.
What is a Referral?
A referral is the coordination between a general practitioner (GP) or a primary care physician (PCP) with a medical specialist on providing the appropriate medical care and supervision for a particular patient. Referrals are usually done through a referral letter from the GP or PCP to the medical specialist.
The referral letter contains the specific medical reason why the GP or PCP is requesting the assistance of the medical specialist for further testing or medication. It also includes the various information necessary for the medical specialist to approve the referral and determine the proper course of action. The information can include the patient's medical history and medications for the disorder.
Health maintenance organizations (HMOs) and Point of Service (POS) plans usually treat referrals as pre-approvals that patients receive from their PCP allowing them to visit a medical specialist in the same HMO. Usually, medical specialists do not see patients if they do not have referrals from their PCP, even for previous patients.
Early detection of a disease is essential for saving lives. However, health institutions only have a limited staff of medical specialists. Referrals help reduce the volume of patients that visit the specialist by screening them with the help of the PCP. Through this screening process, waiting times for patients to see a specialist is significantly reduced.
The Referral Process
The referral process starts with PCP's interaction with the patient. The PCP will check all the symptoms of the patient and provide a list of medications to potentially improve their condition. If there are no improvements in the patient's condition through medication, the PCP can opt to refer the patient to a medical specialist.
The PCP will explain to the patient the reasons for the referral. They will also explain the importance of referrals and when they provide referrals to medical specialists. They will also detail some of the expectations that patients should have when visiting a medical specialist.
Referrals usually have waiting times before approval. The best specialists in the field are sometimes fully-booked and referrals can have long waiting times. However, for critical cases, the PCP staff can make the appointment to see a specialist and gives the information directly to the patient.
The patient can contact the specialist to discuss the important details of the referral, specifically the procedures required, the length of treatment, their communication platform, and the healthcare management plan. This can also include the specific roles of the staff throughout the treatment and recovery process.
The medical specialist and the PCP are in constant communication throughout the treatment process. Usually, the specialist will send the details of the treatment and the test results to the PCP while the PCP communicates this information to the patient. The PCP requires a standardized list of information from the patient to avoid confusion and increase the likelihood of approval from the medical specialist.
Referral to a Gastroenterologist
Gastroenterologists are specialists in the condition of the gastrointestinal tract. This includes the digestive organs from the esophagus to the rectum. Gastroenterologists study for 3 years to become an internal medicine physician after medical school and study again for 3-4 years to specialize in GI tract diseases.
Most HMOs and insurance companies require patients to have a referral letter from an authorized PCP in their network to cover the cost of the visit to a gastroenterologist. Some gastroenterologists, however, accept patients even without a referral but the insurance company might not cover the cost of the visit.
On most occasions, it is best to see a PCP first to check the symptoms and provide medication to see if symptoms respond to medicine. Following the process prescribed by the insurance company can save costly visits to a gastroenterologist. It will also prevent unnecessary costs for diseases that can be cured with prescription medication given by PCPs.
Referral from the PCP is also needed before visiting a gastroenterologist to provide the medical specialist with all the necessary information needed for diagnosis and treatment. The primary role of the PCP in the referral process is to relay all the necessary background information to the gastroenterologist and provide the exact procedure that they need from the medical specialist.
Usually, referrals from the PCP to a medical specialist last for only one year. However, for cases of chronic and continuing gastrointestinal conditions that require continuous treatment, the referral can cover an indefinite period.
PCPs, however, will provide the final decision on the referral to a gastroenterologist. Since they have the full scope of the patient's condition, they make decisions to refer to a medical specialist based on the degree of the symptoms and the medical history of the patient. The patient cannot self-refer to a specialist given that specialists usually require the full spectrum of information from a patient before evaluating on approving the referral.
Once the referral to a gastroenterologist has been approved, the gastroenterologist can conduct a series of examinations to determine the cause of the symptoms. Usually, the diagnosis begins with a physical examination by pressing down on the abdomen to feel any mass forming or tenderness along the GI tract. They will also listen to the patient's breathing and coughing as well as his or her bowel sounds.
For symptoms related to the colorectal area, they will put a finger into the rectum to feel any lumps and assess the texture and tenderness of the rectum for possible signs of a colorectal disorder.
A deeper diagnosis can involve endoscopy, colonoscopy, and barium swallow to check the physical condition of the GI tract. These are more invasive procedures that are reserved for patients with more serious symptoms of GI tract disorder. PCPs usually refer patients to gastroenterologists to perform these services and provide them with detailed results of the examination.
Gastroenterologists themselves can also issue referrals to other physicians to solicit their opinion on the proper course of action given the diagnosis of the patient. They can issue referrals to colorectal surgeons to determine if surgery is necessary for particular cases. They can also issue referrals for other diagnostic imaging examinations that are outside their expertise such as X-ray scans, CT scans, MRI scans, and pathological tests such as stool and blood tests.
Success of Referrals to a Gastroenterologist
The referral process to gastroenterologists has become stricter over the years as the medical specialists have become overwhelmed with the volume of patients referred to their department.
In the UK, a combination of two or more specific symptoms of the gastrointestinal disorder can raise the urgency of a referral. Specifically, the combination of any two of the following symptoms: anemia, rectal bleeding, and radical shift in bowel movement, is a potential high-risk for colorectal cancer.
The Two-Week Referral Rule in the UK refers to the kind of urgent referral for patients who experience symptoms such as radical weight loss, abdominal pain, dysphagia, dyspepsia, jaundice, vomiting, and anemia.
PCPs can also provide an early referral for endoscopy for patients with symptoms like anemia, rectal bleeding, abdominal pain, dysphagia, and anorexia. Patients with these symptoms who have a history of peptic ulcer and are frequent smokers and alcohol users are frequent candidates for referral for early endoscopy for gastroenterologists.
There are also established guidelines for urgent referrals for both lower and upper GI tract disorders. For the upper GI tract, symptoms that may warrant urgent referrals are progressive dysphagia, dyspepsia with radical weight loss, anemia with vomiting, and haematemesis. For the lower GI tract, the combination of two among these three symptoms warrants urgent referrals: anemia, rectal bleeding, and change in bowel movement.
Referrals provide the gastroenterologists, as specialists in the condition gastrointestinal tract, the full breadth of information required to make, not only a sufficient and adequate, but most importantly a successful diagnosis and treatment process for a patient.
Patients are urged to follow the referral guidelines of their HMOs and POS when looking for a gastroenterologist to avail of a cost-effective and insurance-covered healthcare service.