• Christopher B Forrest, Paul A Nutting, Barbara Starfield, and Sarah von Schrader.
• Health Services Research & Development Center, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD 21205, USA. cforrest@jhsph.edu
• J Fam Pract. 2002 Mar 1;51(3):215-22.

ObjectiveTo examine family physicians' referral decisions, which we conceptualized as having 2 phases: whether to refer followed by to whom to refer.Study DesignProspective cohort study.PopulationAll visits (N = 34,519) and new referrals (N = 2534) occurring during 15 consecutive business days in the offices of 141 family physicians in 87 practices located in 31 states.Outcomes MeasuredRates of referral, reasons for referral, practitioners referred to, health problems prompting referral, and reasons for selecting particular specialists.ResultsApproximately 1 in 20 (5.1%) office visits led to referral. Although 68% of referrals were made by physicians during office visits, 18% were made by physicians during telephone conversations with patients, 11% by office staff with input from the physician, and 3% by staff without physician input. Physicians endorsed a mean of 1.8 reasons for making a referral. They sought specialists' advice on either diagnosis or treatment for 52.1% of referrals and asked the specialist to direct medical management for 25.9% and surgical management for 37.8%. Patient request was one reason for 13.6% of referrals. Fifty conditions accounted for 76% of all referrals. Surgical specialists were sent the largest share of referrals (45.4%), followed by medical specialists (31.0%), nonphysician clinicians (12.1%), obstetrician-gynecologists (4.6%), mental health professionals (4.2%), other practitioners (2.0%), and generalists (0.8%). Physicians recommended a specific practitioner to the patient for most (86.2%) referrals. Personal knowledge of the specialist was the most important reason for selecting a specific specialist.ConclusionsReferrals are commonly made during encounters other than office visits, such as telephone conversations or staff-patient interactions, in primary care practice. Training in the referral process should ensure that family physicians obtain the skills necessary to expand their scope of practice, when appropriate; determine when and why a patient should be referred; and identify the type of practitioner to whom the patient should be sent.

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