Most of us are fortunate to have a primary healthcare provider who is able to take care of the vast majority of our medical needs. For certain conditions and symptoms, however, more specialized care is required. We access that specialized care through the medical referral system.
In fact, nearly all insurance companies require a referral from your primary care provider to cover any specialist appointments or care (and many specialists require a referral to see you). And it does make sense. Your primary care provider is the gatekeeper of your medical care. If your symptoms are outside of the common illnesses or conditions your primary physician is qualified to manage and treat, he/she should send you to a physician who can provide more specialized care. Because this process relies on a physician’s subjective assessment, problems can arise, including failing to refer a patient to a specialist when it’s needed. Often that need is only made obvious when symptoms worsen significantly, putting the patient at greater risk.
Here are some of the reasons a physician should refer you:
They are unable to make a clear diagnosis. Many symptoms can be attributed to a number of conditions. If your physician isn’t sure why you’re experiencing your set of symptoms, consulting a specialist should be the next step.
You require care or a procedure that is outside their knowledge and expertise. There’s a reason specialists exist. No general practitioner can be an expert in every area. Your primary care provider should ensure you have access to the level of expertise and care you need.
You continue to experience symptoms they’re unable to adequately address. It’s not normal to have your quality of life significantly impacted over a long period of time by symptoms that won’t go away. It may be time for your physician to seek another opinion in finding a root cause for persistent symptoms.
It sounds fairly straightforward, but why won’t a physician refer when it seems called for? Perhaps it’s because your doctor thinks he/she adequately understands your symptoms and doesn’t believe there is cause for concern. Or, maybe you require a procedure he/she thinks can be sufficiently managed by your primary care practice. That can be a costly mistake and even constitute malpractice under certain circumstances. The physician’s own unconscious biases may also be in play (see our blog on The Impact of Healthcare Bias on Women to learn more).
As a patient, here’s what you can do to prevent referral issues:
Don’t accept the first answer. We often back down when our doctor doesn’t seem to be concerned and minimize what is happening with us medically. After all, they have the medical degree. Understand you are in the best position to know what is happening with your own body and when it is unusual or concerning.
Speak up. If you are having unusual symptoms which concern you, but your physician dismisses them as “minor,” ask for a referral anyway. If needed, make another appointment to discuss. Calmly ask why your physician doesn’t feel a specialist is needed and share why you do. (Read what you can do when your physician ignores your concerns, “Have Symptoms That Won’t Go Away?”)
Assess the relationship. Understand the relationship you have with your primary care provider. If you’re not comfortable and see signs you’re not being listened to and understood, consider finding another provider sooner rather than later. The stronger your connection, the more likely you will be heard when the time comes to be referred to a specialist.
If you believe you’ve suffered unnecessary pain or medical issues as a result of your primary care doctor’s failure to refer you to a specialist, don’t go it alone. Consider consulting with an attorney who can help you navigate next steps.