“We sent in a referral right after your last appointment. It’s not our fault that the psychiatrist won’t see you or that you have to wait for over a year. Blame them — we did our best!”
In a previous post, I alluded to the poor quality of referrals we often receive from telehealth, episodic care.
While I’m more inclined to bitch about the mental health services side of things and stand up for overworked family docs, there’s some blame on that side of the fence. Though who is responsible may surprise you.
What you expect to happen
Many people go to a family doc when they’re struggling with mental health. That’s what we tell them to do. Increasingly, it’s via a telehealth service since they don’t have their own family docs and walk-in clinics are jammed or closing.
You might directly ask for a referral to a psychiatrist. Or, in the course of the brief appointment, the family doc you see tells you a referral would be the best thing to do. They promise to refer you.
As the “gatekeepers” to the specialists in our system, you expect the family doc to decide if the specialist needs to see you. If they send a referral, then a specialist should see you. Hopefully sooner than later, but you’ve heard that waits can be long…
What you see happen
Hearing nothing for several weeks, you arrange another appointment with the family doc (or someone else working through the telehealth service). They tell you they’ve tried to refer you to several places. “Nobody is accepting patients” or “they wouldn’t see you” or “they’ll contact you when they have room to see you, but it might be six months or a year… we really don’t know.” But it’s not the fault of the GP!
There’s some truth to that. But let me show you what you’re not seeing.
The other gatekeepers
When a referral gets sent to a specialist or specialist service, it’s reviewed by someone, whether a doctor, nurse, mental health manager, dedicated intake worker, etc. In my wife’s solo private practice, it’s first me.
Specialists have referral criteria: what patients they’ll see, who they won’t, what information they need sent. Some prioritize more urgent referrals (triage). Sometimes (but not always), referral criteria are documented. Ours are clearly stated on our website and referral form. They include things like age (18-64) and the main problem being referred for (mood or anxiety, but not, e.g., psychosis or ADHD).
Given the scarcity of psychiatrists and that she treats most people (vs. one-time consults), there are other restrictions. She doesn’t see people who are stable and want to connect with someone to stay that way or when some basic things haven’t been tried by family docs before referring. And she needs a patient’s physical and mental health history, previous records if available, lab work, and a few other things. Not all practices ask for all that, but she does and uses it to help prioritize.
Before all the telehealth care, we used to joke about some referrals we’d occasionally get. They’d have just a patient info sticker and the single word “depression,” or the Canadian-ized variant, “please see for depression”.
Our experience with telehealth referrals
I took a look back at the referrals that came into my wife’s practice from telehealth docs that we did not accept. On a quick scan, I pulled out 33 from our records (there were probably a few others I didn’t catch). They were from a range of different telehealth providers (Telus Health was the largest in the batch, with 13 referrals).
Throughout this, I’m using “telehealth docs” as a shorthand for the episodic care that happens when you use one of these services that connect you with a random doctor from whereever. That’s very different than your own doctor seeing you via phone, Zoom, etc.
Here’s what I found:
- 22/33 were sent at a time when we were not accepting patients (we stop accepting referrals when our waiting list gets to a certain point)
- 3/33 were for patients outside our age range (11, 12, and 15)
- 10/33 were for patients whose primary reason for being referred was to get an ADHD assessment (which we explicitly say we don’t do)
- 4/33 were for other things we don’t do, e.g., find a counsellor, or were stable
What required information was (wasn’t…) included in the referrals?
- Not a single referral provided any lab reports, though 3/33 did give a requisition to the patients to get the tests we asked for
- 2/33 provided previous records (both had been sent to the service in advance by the patient), with 3/33 others having enough information we could infer that the person hadn’t seen anyone before, i.e., no records exist
- Only 7/33 provided any information whatsoever about the patient’s physical health, or even “no physical health concerns”
- 8/33 did not mention any medications the patient was currently taking or even “not on any prescribed meds”
- 26/33 appeared to be, with the most generous interpretation, a clear “dump” to psychiatry when no interventions had been tried through primary care
And yes, we tell the referring doc why it was not accepted and they can resubmit with missing info — not uncommon for “regular” family docs to do. And if, for example, it just didn’t include labs, we’d accept it and ask the referring doc to order labs.
The “dump” referrals are worth highlighting, given the shortage of psychiatrists and long waits. Not offering any care whatsoever at the primary care level — particularly given the wide range of reasonable interventions well within the scope of any family physician — may be a real disservice to the patient.
The waits are long everywhere in BC, so not knowing is not an excuse. It’s probably worst on Vancouver Island. But then again, at least 22/33 were from doctors we could identify (with digging) to be from the mainland. They’re at a distinct disadvantage in not being familiar with area resources. Only 1/33 was from a doc elsewhere on Vancouver Island (several we couldn’t tell).
On the plus side, the referrals were mainly (30/33) for patients who lived on Vancouver Island, mostly in Victoria.
Standards for referrals?
There are actually standards for referrals mandated by the College of Physicians. Many referrals pay lip service to them. The Telus Health referrals are four–five pages of boilerplate, often filled in with three lines of actual information. Sections like “Reason for Referral” may just say “depression”, “Expectations” may say “management”, “Relevant Clinical Information” may be two lines, and “Relevant Labs, Reports, …” may be left blank.
And my favourites (this is a recent thing) are referrals that are 95% autogenerated textual versions of the patient’s answers from mental health scales (e.g., PHQ-9, GAD-7, …). These were obviously completed online in advance of their telehealth appointment. Don’t get me wrong, I love scales, but they aren’t a referral and are much easier to read if you don’t try to turn them into prose.
The contrast with some of the referrals we get from family docs providing longitudinal care couldn’t be greater. They’ll spend months or years working with the patient, trying all kinds of reasonable things that didn’t fully work. When they’re referred, they come with a ton of supporting documentation.
Whose referrals do you think get accepted more often because they actually meet referral criteria?
Of course, not all “regular” family doc referrals are that good. Some we get from in-person walk-in docs aren’t much better than the telehealth ones described above. And not all telehealth ones are horrid. But as a general rule, the telehealth ones are in a class of their own.
And how many referrals did we accept from pure telehealth services?
During the timeframe we received those 33 (rejected) referrals, I know for a fact that we accepted only 2 that came through a telehealth service:
- One was a patient who contacted us first, who was given explicit instructions on what they needed to get through the telehealth doc and provided a good part of the information themselves.
- The other referral was a bit sparse but said a couple things to suggest more might be going on. I contacted the patient to get the rest of the story and then arranged to get their previous psychiatrist’s records.
We generally get back to referring docs quickly if we can’t take a patient. But in many places, two weeks is the standard. For a bad referral that never had a chance of getting accepted, that’s two weeks you’re not getting better and wasted time in both the referring clinic and the specialist’s clinic.
So to anyone who thinks that episodic care through a random telehealth provider is a “good enough” substitute for a real family doc… guess what? It’s not.
Incidentally, I (mostly) don’t blame the individual docs. They’re forced to practice in walk-in clinics and telehealth services where they can’t reasonably provide good quality care and make a living. As we all know, there isn’t proper financial support for full-service family medicine practices.
What can you do?
This does leave patients, who often don’t have (and can’t get) a family doctor, completely screwed.
However, there are things you can do to improve your odds of getting better care.
Collect previous records and (even better) prepare a concise summary of prior history, current concerns, and needs. A referring doctor who doesn’t know you can easily attach it to a psychiatry referral. That can go a long way. If you know who you’ve been referred to (or have someone in mind), consider reaching out to their office.
You shouldn’t need to do these things. And unfortunately, not everyone is in the mental space to do them or has people to help them. As usual, the people who most need the help are least likely to get it.
Related: see all Victoria posts here