Typologies in GPs’ referral practice

The questionnaire and the referrals registration form were designed by the authors on the basis of the results from a previous study, where we found that many GPs consider referring as asymmetric and sometimes humiliating [13]. The four first statements (A1-4) in the questionnaire focused on problems and uncertainty when referring. Having a special interest in communication in the referral process, GPs’ workload and patients’ pressure to be referred, these are elements which may have had an impact on the choice of questions and statements. Other, more positive and optimistic questions and statements might have given other components and typologies. The questionnaire and the referral registration form were designed in collaboration with experienced academic and non-academic GPs and were piloted among other GPs, without any suggestions for changes. Feedback from the participants supported the assumption that the questions and statements were relevant and easy to score.

The first author was responsible for all information to the participating GPs. Being a colleague and a known person for many of the participants, and having an agenda on a better referral process for all, this personal factor may have a positive impact on the response rate.

The response rate was 44.5% (19% of all the GPs in our region) which raises the concern of a selection bias. Similar studies among GPs had response rates from 42-47% [12, 26]. Among the participants a large part was specialists (88%) compared with those who didn't participate (61%). This could affect the interpretation of the results in direction of an over-focus on the confidence elements among the experienced specialists, whereas the younger non-specialists over-focused on the uncertainty elements may cause a bias which means that the differences between the two typologies are even bigger than in our conclusion. However, as no significant differences were found between participants and non-participants in the 23 CPD group meetings for the statements on the referral process we consider our results to be representative for Norwegian general practice and for countries with similar health care systems.

The questionnaires were filled in anonymously during CPD group meetings, securing each GP’s confidentiality. The participants were instructed to score the referrals consecutively and immediately when or after referring, which is considered to be a strength for the study, because of minimalized recall bias. We have, however no guaranty that all referrals have been registered.

In the PCA, three of our components had two overlapping variables (A5 and 7) (Table 3) meaning components are mainly unique. A 77% cumulative variance covers most of the variations in the material, indicating an adequate description of the referral process, a considerable strength for our study.

The 57 participants registered a total of 691 referrals during the registration period. As they did not register the number of consultations during this month, we cannot calculate the actual referral rates for our participants, or know if the referral rates were different from those who did not participate. This means that we cannot tell if our participants are within the normal range of variation according to referral rates, or whether this has any impact on the results. Our components and typologies could have been different if we had included the referral rates in the variables for PCA.

By abduction of the eight principal components we found two typologies. Others could have chosen another approach. The principal components are independent quantitative variables, whereas the abductive reasoning can be seen as a creative inference, involving integration and interpretation of ideas to develop new knowledge. In abductive reasoning the premises do not guarantee the conclusion, but can ensure a pragmatic validity [27].

This is to our knowledge the first study of typologies of GPs in the referral process. Other studies on typologies in medicine have been done to explore professional identity of nurses [28] and hospital specialists [29]. Our two typologies represent aspects of the referral process where most GPs will recognize themselves. Elements in the confidence typology are found in other studies [30, 31]. Collaboration with patients and colleagues are important elements in the referral process, often associated with better health outcomes and improved patient satisfaction [32]. Already in 1992 Huygen et al. found that the integrated style GP can further the health and well-being of their patients [33]. Patients want to know how long they must wait and who they will see [31, 34]. Little et al. found that doctors' behaviour in the consultation was strongly associated with the perceived medical need of the patient, that a minority of examining, prescribing, referrals and investigations were thought by doctors to be slightly needed or not needed at all and that the perceived patient pressure was a strong independent predictor of all doctor behaviours [35]. They concluded: “To limit unnecessary resource use and iatrogenesis, when management decisions are not thought to be medically needed, doctors need to directly ask patients about their expectations”. Ringberg et al. found that the issue of the referral was introduced by the patients in 29.4 % of cases [11]. Our finding echoes these results and the results of Donohoe et al., who found that patients’ requests influenced referral decisions in one fifth of the cases [36]. Ringberg et al. found that female GPs referred more often than male to reassure the patient because they experienced lack of medical knowledge and when the issue of referring was introduced [12]. A low referral rate was one of the characteristics of the integrated practice style, with maximum scores on patient- and goal-oriented approaches. Low referrers were more confident about their decisions, more positive about alternatives to hospital admission and more able to resist pressure from families and carers to have someone admitted; they saw hospitals as places to be avoided and viewed their goal as preventing an admission [10].

The uncertainty typology matches our findings in a previous study, where we found that many GPs consider referring to be asymmetric and sometimes embarrassing [13]. Other studies have shown that younger doctors are more vulnerable to patients’ scepticism and criticism, and that individual uncertainty among GPs about referring has a significant impact on higher referral rates [10‐12, 16, 37]. Calnan et al. found that high-referring GPs were more cautious and believed that it was better to admit if in doubt. The high referrers in their study expressed anxiety about the consequences of a decision not to admit, both for the patient and for themselves and they held negative attitudes towards alternatives to hospital admission. The uncertainty typology encompasses those who seldom contacted a hospital specialist when they referred. In Berendsen et al’s study 73.2 % of GPs answered that a hospital specialist could easily be reached for a colleague consultation [26]. Earlier studies have shown that both GPs and hospital consultants called for more contact and communication in the referral process [13, 14]. Heavy workload describes a well-known situation for many GPs, who use much time when they refer, experiencing many difficult referrals and who do not think that referrals could have been avoided if they called a hospital specialist. In an Israeli study published in 2014 Kushnir et al. found higher referral rates for diagnostic tests and specialist clinics for physicians with burnout symptoms and when objective workload increased [38].

The last years’ development of better e-communication and more advanced electronic referral decision support systems have facilitated an easier referral process [18, 19], making it more convenient to complete the referrals during the consultation, which may be timesaving and associated with less work-load.

Our results support the conclusion in Calnan et al’s study, which calls for educational programmes to improve GPs’ judgements of their competences and to build appropriate levels of confidence [10]. Our study adds that a patient-centred practice, easy access to confer with a hospital consultant and good cooperation with patients when making the referrals may be a major topic for CPD groups and vocational training for specialists in family medicine.