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Between Pediatric Generalist and Specialist: Room for Improvement

We need to improve physician-to-physician communication regarding referrals.

Effective communication between pediatric generalists and specialists who care for children with chronic conditions is a challenge. Poor communication is associated with more time-consuming care, delayed or missed diagnosis, test duplication, delayed treatment, potential adverse drug reactions, and parental dissatisfaction. A previous pediatric study indicated that specialists communicated findings to referring generalists in only 51% of cases and outlined plans for sharing care in only 31% (see Arch Pediatr Adolesc Med 2000; 154:499). These researchers examined communication patterns between pediatric generalists and specialists providing outpatient care in New England.

Among 412 clinicians who completed mailed questionnaires (48% of mailings), 98% agreed that communication was important for assuring good care. Although 60% of generalists reported frequently sending information with initial referrals (>60% of the time), only 28% of specialists reported frequent receipt of information before seeing patients. The same pattern was seen after specialists' initial consultations: 92% of specialists reported sending reports frequently, whereas only 70% of generalists reported receiving reports frequently.

Barriers to communication included difficulty making telephone contact, automatic phone menus, delayed transcription of dictation, and specialists referring patients to other specialists without notifying the generalists. Important facilitators of communication included preconsultation letters or phone calls from the generalist with specific questions and postconsultation letters or calls from the specialist. Significantly more generalists than specialists saw communication as problematic (40% vs. 28%). E-mail was underused: 87% of participants had access, but only 10% used it very often.

Comment: This study documents a lack of consistent communication between pediatric generalists and specialists. The difference in perceptions of information sent and received is striking, although, I suspect, unsurprising to many readers. The authors provide some solutions: Provide timely, systematic information before referral and after follow-up visits; ask specific questions; discuss co-management; improve the facility of phone contact; and ensure that the family is not the sole source of communication between providers. In addition, it may help to assign someone in the office to coordinate all referral letters -- and perhaps it's time we communicate with our colleagues by e-mail.

— Martin T. Stein, MD

Published in Journal Watch Pediatrics and Adolescent Medicine February 17, 2004

Citation(s):

Stille CJ et al. Generalist-subspecialist communication for children with chronic conditions: A regional physician survey. Pediatrics 2003 Dec; 112:1314-20.

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