Strategy to diminish nonresponse

Neimanis et al report that 36% of all requests from primary care physicians for specialist consultation in Hamilton, Ont, were not responded to by the end of their study’s follow-up time of 5 to 7 weeks.¹ This experience is likely mirrored, anecdotally, in many communities. Emergency physicians also make elective specialist referrals and run into similar problems. Furthermore, as an emergency physician, I often see people who come to the emergency department thinking they can work around the problems of non-response for a consultation or a prolonged wait for either a consultation or diagnostic procedure. As frustrating as these encounters are, these patients are simply trying to make an uncertain, unresponsive system work for them. Neimanis et al shed descriptive light on the problem of nonresponse to a request for consultation. However, most of the suggestions to solve the problem, including those from the Canadian Medical Association “toolbox,”² are general and not helpful.

I use the following strategy to diminish non-response for an elective consultation from a specialist. When I make a referral, I write out the name of the specialist for the person and tell him or her that he or she should receive a call from the specialist’s office regarding an appointment time by a certain date (usually about 1 week). If he or she does not hear from the specialist’s office, he or she is to call the office and ask if the specialist received the referral. If the office did not receive the referral, the person phones the emergency department and asks for the referral letter to be faxed again. If the specialist’s office acknowledges receipt of the referral, then the person should ask when the appointment is. If the consultation date has not been fixed, then the person should ask by what date the specialist’s office will notify them about the consultation. If he or she has not heard by that date, call again and go through the same procedure. I emphasize to the patient to be polite but insistent in pinning down dates. Patients should try to be perceived as just seeking information they deserve to have. The squeaky wheel gets the grease.

Patients can generally handle waiting for an appointment when they know when it will be. They can adjust their expectations or seek a referral to a different consultant if the wait time seems excessive. What is difficult and frustrating is the uncertainty of not knowing when or even if a consultation will be booked. I am amazed when I see people who tell me they were referred 6 months ago to someone, whose name they never knew or have forgotten, and they have not heard back from their family physician or the specialist about when the consultation will take place. Their faith in the system is touching but naïve. They patiently wait politely for a telephone call that might never come.

Until patients and primary care physicians indicate that nonresponse to a request for consultation is unacceptable, we enable this behaviour to continue.

• Copyright© the College of Family Physicians of Canada