Our Perilous Patient Referral System

Our Perilous Patient Referral System
The first quarter of the twenty-first century is almost over, and yet our healthcare outcomes remain dismal, defying all innovation that science daily adds to medicine. A big reason behind this failure is delayed diagnosis, a tragedy that itself points to many factors. True, many patients reach the final stages of the illness primarily because of our poor healthcare structure that makes it quite difficult for them to navigate the system.

But there is another large group of patients who have the means and mental capability to deal with their disease, who take all precautions, follow up with doctors regularly, and yet fail to do any better. What goes wrong with this potentially salvageable section of our patients? What makes our physicians poor clinicians when it comes to judge the time for referring their patients to a different level of care? The answer is the patient referral system.

Before diving into these factors, we first need to understand what patient referral means. All of us have either heard about or experienced miracles of modern medicine, a treatment, a procedure, a cure, unknown or unavailable just a generation ago. The backbone of this jaw-dropping progress in medicine is the evolution of specialty care.

Along with a quest for precise diagnosis and treatment, which propelled the production of new drugs, better lab tests, and high-tech imaging techniques, we need doctors who prefer to practice in a particular domain. So, as the science of medicine continued its evolutionary march, medical practice ramified into multiple subspecialties—cardiology, nephrology, oncology, infectious diseases, radiology, pathology, and so on and on. In any developed country, healthcare looks like this multispecialty service, where various experts contribute to treating a single patient, each giving his best.

Such practice may look fragmented, but it has become the standard of care in the modern world. However, for such a system to work, all healthcare associates, including doctors, nurses, and other ancillary staff, must acknowledge each other's knowledge and skill, building healthy boundaries with mutual respect. Once these principles solidify the system's foundation, referring the patient to another specialty or a doctor becomes an automated process, not requiring much education or persuasion of either the patient or the referring physician.

Now that we know the meaning and importance of referring patients for a different level of care, I assume we all agree that sending a patient for specialised care constitutes not only the best but the essential practice, at least for those who regard patients’ health our primary goal. So then, what holds physicians in Pakistan from adopting this practice?

The most basic reason is our physicians' poor experience during training and the resulting incredulity about the referral practice. In the tertiary care hospitals, which constitute our leading training institutions, the referral system exists at a very primitive level. For a trainee, this system means nothing but a useless exchange of poorly scribbled paper slips, an exercise that plays no role in improving patient health or the trainees' knowledge. This back-and-forth movement of messages has less to do with achieving better treatment for the patient and more with building a legal wall around the slipshod management plan should something go wrong. By the end of the training, a physician firmly believes that referrals bring no significant benefit to the treatment plan.

Furthermore, having received no better advice or new knowledge, doctors-in-training have no choice but to fill this vacuum with improvisation. And once they become pros in devising treatments in which they are not experts, they don't feel the need for experts in managing patients, even when their tricks fail. They keep trying. In real life, however, all this comes at a significant loss for the patient, who could have received better treatment and the best possible outcomes had he been referred for the appropriate level of care.

Even if we train our physicians well and teach them the rewards of appropriate referral, they still find such practice challenging because of the lack of available experts. Most doctors who specialise beyond general medical practice either leave the country for better opportunities or stay in the big cities to keep their skills afloat.

This latter group converges in four cities in Pakistan: Karachi, Islamabad, Peshawar, and Lahore. Things are changing but slowly but yet to be felt by the primary physicians. Even though more consultants and subspecialists, such as heart specialists, kidney specialists, diabetes specialists, and others, are now moving back to their hometowns in smaller cities, the local general practitioners have not sensed this change. Stubbornly ignoring the advancement in medicine, these jacks-of-all-trades keep their patients from specialised care, not realizing how much more they can achieve for the patients by accepting their limits and adopting the referral system.

Many physicians resist the temptation of referral simply for fear of losing their reputation. Our patients, similar to their limited view of an illness, see a doctor as a messiah, possessing all-encompassing knowledge and a cure for all diseases. Under this social pressure, physicians find themselves in a tough spot when they face a patient with a condition they lack the skills to treat. Referring this difficult-to-treat patient to an expert can raise a question about their competency. And it is very likely that, rather than receiving thanks for the appropriate transition of care, the healer may lose the patient to another doctor. Things can get even worst: the referred patient keeps telling others about this "incapable" doctor, starting a negative campaign that can ruin the physician's practice. Scared of such outcomes of their good initiatives, our doctors stifle their good intentions and keep trying different methods from the toolbox of their experience.

It is not just the fear of reputation that hold doctors back from doing the right thing; they have another more powerful concern— financial insecurity. To understand financial security, you must first learn about the basics of the medical business. In medical practice, the consultation fee, viewed by patients as no less than a robbery of their hard-earned money, barely makes any money for the doctor. To supplement this income, most doctors, particularly general physicians, establish a pharmacy and a laboratory within their premises.

This entrepreneurship comes within the bounds of ethics and law, for all patients need medicines and tests, and what can be a better place than the clinic of their trusted physician? However, such practice becomes unethical when physicians prefer their interests over patients', holding back patients from receiving specialized care. This conflict of interest leads to unnecessary patient suffering.

This is how it goes wrong. Typically, in a world where a patient's health predominates the healthcare philosophy, when a general physician refers a patient to a specialist, the patient visits the consultant, who sends the patient back to the primary physician with an expert opinion on the treatment plan. The link between the specialist and the patients continues, often requiring regular follow-up, but the patient always returns to the primary physician. In Pakistan, however, the general physician fears that he would lose not only the patient but also all the pharmacy and diagnostic business because the specialist in our medical practice first sows the seeds of hatred against the previous physician and then suggests new medicines and tests, acceptable only if done from the place suggested by him. In short, the new physician keeps the patient and the business.

Nevertheless, blaming the physicians for the whole affair also seems unfair. Part of the problem lies in the illiteracy and poverty of our patients. They have neither the money to consult one doctor for each illness nor the mental capacity to manage the pile of papers resulting from multiple doctors. Our patients see cure from a miracle viewpoint, their default expectation being a "cure" from a doctor with "healing powers." Despite all scientific progress around us and slight improvement in our literacy, our patients remain unable to comprehend the concept of disease management with evidence-based medical knowledge. In this context, if a doctor opts to keep a patient under his auspices without consulting the experts, it is hard to tell whether he did a favour to the patient or held him back from a better treatment.

In a healthcare system like this, where the basic structure is sloppy, where personal interests trump the patients’ health, all parties lose, physicians their dignity, the healthcare system its trust, and the pharmaceutical and diagnostic industry their legitimacy, but the party that loses the most is the patient. Innocent and vulnerable, the sick citizen, after raising his hands toward heaven, knocks at the doors of doctors, hoping to find a cure for his illness, unaware that the system he is approaching is sick itself and in dire need of a cure.

Will our healthcare system ever be cured of its maladies?


The writer is an Internist and Nephrologist. He has won Top Internist Award in 2021 and Top Nephrologist Award in 2022 from Michigan, USA. He can be reached on Twitter @awaiszaka