The act of referring a patient to another more experienced or knowledgeable physician for a consultation or procedure is commonplace in contemporary medicine. Nearly all physicians make referrals and, although I am unaware of any data to support this, it seems to me that physicians refer to colleagues more than most other professions. A provocative viewpoint piece recently submitted to the Journal discussed factors that sometimes influence the selection of the individual who is to receive the referral. This paper provoked a lengthy and spirited discussion among the editors, and engendered this Editor's Page.

There are many reasons that physicians refer patients. Given the increasing specialization of the profession, it is not uncommon to encounter a problem for which another doctor has more experience or knowledge. A consultation can solve the problem for the patient and also serve to educate the referrer. Often, procedures are indicated that the attending physician does not perform. Sometimes it is good just to get a second opinion to confirm your own thoughts or in regard to cases where you have been unable to identify the diagnosis or achieve successful treatment.

Regardless of the situation, the decision of when and to whom a referral should be made is one of the most important decisions that a physician has to make. On occasion, patients will have had prior contact with another doctor or have a clear preference as to whom they would like to see in consultation. More commonly, patients defer to their attending physician and trust in his or her judgment to make the best choice. In this regard, the decision of whom to refer to is as important as any determination of which test to perform or therapy to administer. It may be even more important for cardiologists; the final result of an evaluation for chest pain may depend more upon the interventionist or surgeon than upon the determination of the procedure to be performed. The same could be said for the electrophysiologist who performs an ablation on a patient with atrial fibrillation.

A number of considerations go into the decision of to whom to refer. The longstanding tongue-in-cheek description of the most important characteristics of a good consultant has been the three “a”s (in order: availability, affability, and ability). Geographic considerations are often significant factors and, regrettably, insurance arrangements and managed care increasingly represent nonmedical issues that dictate the choice of consultants. The major factor, however, should be the track record of the consultant. For each of us, the experience of how our patients have done after consultation and/or procedures is almost certainly the most important factor in deciding whom we refer to. However, we may be in the position of referring for a problem with which we have not had much experience. Therefore, it behooves us to know, not only how well our own patients have done, but also the overall performance of colleagues whom we might consult. Such information is not always readily available.

A number of socioeconomic issues exist that may influence the choice of a consultant. Having an office in the same medical building or belonging to the same country club or even church often determines referral lines. Practicing in the same hospital is also often of fundamental priority in deciding to whom to consult. Those of us on university faculties or in multidisciplinary group practices have strong financial and social ties to our colleagues/partners, relationships that present an extremely strong incentive to refer to these individuals. On occasion, these relationships may even result in a slight pressure to refer “in house,” even if the results are not as good as elsewhere. In such circumstances we must resist the pressure. It is crucial to remember that our primary allegiance is to our patients and to get them the best care possible.

Fortunately, the standards and quality controls within medicine are so high that choosing from a group of possible consultants is usually not difficult. However, from time to time situations may arise in which slight pressures are exerted to refer to one specialist rather than another. In such circumstances, it is well to remember our obligation to our patients and the trust that they have placed in us. For me the decision is easy; I only refer to those individuals who I would want to care for me or my family if either I or they were ill. As in most things, this medical “golden rule” is a great basis upon which to decide to whom to refer.