Referral’s nightmare week!

Posted on July 16, 2009. Filed under: Journal from behind the desk... |


Good Grief.

Obviously part of my role is to identify patients who can’t be managed in Primary care and need to be referred on to a specialist consultant.  In days gone by there were concerns that a mere Nurse Practitioner surely wasn’t competent to refer onto a super human like a consultant. Mostly we have worked very hard to prove that we could.

Despite initial fears, we proved that our referral rates were much the same as other clinicians and in some case less (probably because if we were ever unsure we referred to the GP who then may have referred on anyhoooo..)

One service still refuses our NP referrals despite our best attempts to convert them. I still refer and the GP just state: “I completely agree with this referral” on the bottom and thus it gets through.  Otherwise I have no problems, except for…..the bleeding patients.

On a very few occasion (about one every three months), a patient may feel they need a referral, and this can usually be addressed and either agreed or rationally explained and disagreed, but apparent this week is “National Be Snotty and Demand a Referral Week!”  Did anyone else see the publicity campaign???

My first case was a dad presenting with his school aged son, immediately demanding a referral to a Respiratory consultant to “cure his asthma” as nothing else worked.

I looked in the notes and the child had last attended surgery 6 months ago, with a mild cough and was simply advised to monitor his peak flow and increase his steroid inhaler if it dropped below 80% of his predicted range (which as yet it hadn’t).  I also noted that he had not had a repeat steroid inhaler prescription since.

I tried to ask the basic questions, and also asked whether they had been using a steroid inhaler recently. The torrent of abuse worsened and continued. I was advised that the patients mother was an “big in the city” ….

…and was demanding a referral and that his father was also an important figure in the health service and thus I should refer him to a consultant….

MY HECKLES ARE NOW UP…. but I stayed cool!  “I only refer based on clinical need” I explained and I add “Any respiratory consultant in the country would insist that you use the basic treatment and they will only accept a referral if this is not effective”.

But still he fires on.  At not point during the consultation was the child allowed to be examined. In the end I copped out a little and told them if they were unhappy with my decision to feel free to discuss it with a GP and I made them an appointment for 5 minutes later, to which he continued… “this is not good enough”.   I think he’d stopped listening at this point.

They stormed out and saw the GP, who gave them a steroid inhaler!

Apart from winding me up because he was point blank rude and ignorant (no matter how “influencial” he was!), I felt really sorry for the poor child, firstly having to witness such a tantrum, secondly for having to see their own parent behave in such a manner and thirdly for having a physical condition that simply wasn’t being managed properly due to ignorance, for which I could have given good advice but wasn’t given the opportunity.   I felt a little like asking the father to leave, so that I could help the patient…not sure that would have gone down so well ( I also avoided mentioning that holding back on prescribed medications was essentially child abuse!… I know, somedays I  am just too weak!!)  If I could have done a referral it would have been for the father to see someone in a mental health facility.

My second case was a teenage boy who had been convinced by his mother that he had a neurological condition, when infact he had a fairly convincing case of tendinitis. The teenager himself understood what I was saying and my rationale for why it wasn’t a neurological concern.  The mother however just kept on and on. In the end I think they went to the Emergency room to demand they see a neurologist.  Good luck with that one then!!!!  At least they were not aggressive, but just persistent.

I need a dwink! hic.

Apparently it reduces my risks of dementia…according to research a moderate drinker has lower risks…or at least they might just be too pissed to tell!  I’m sure if I drink enough I actually get dementia symptoms, but I just stop caring about them and anyway who would notice.  “Ahh , he’s just drunk”

Anyway….I frunckin’ lurrrrve you….hic.

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6 Responses to “Referral’s nightmare week!”

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It’s not “essentially” child abuse, it IS child abuse. Medical neglect. Are nurses mandated reporters? I’m a teacher, and I’d hotline that jackass in a heartbeat 🙂

referring patient isn’t easy, it must be diagnised first.

Well Kay you are of course right. But if I referred everyone who wasn’t using a treatment regieme as Prescribed, I might as well have a social worker in the room with me! Tempting to do a referral to child Protection team just to rattle the father some more! :-0

I so agree about the difficulty of getting proper referrals done. The ones I do get processed often come back addressed to my collaborating MD as “Dear Dr. So and So, Thanks for sending me the referral… not ever acknowledging that I was the one who sent the patient and addressing me as Dr. Scott instead of my title of NP. Aggravating!

[…] Max E. Nurse from It shouldn’t happen in health care gives us a bit more insight into the world of nurse practitioners with Referral’s Nightmare Week! […]

I find the parents of children who have resp problems are usually scared. THey do not want to medicate their children with steroids. Sometimes referring to an allergist can be more beneficial then treatment with steroids. I have seen many children with asthma decrease their need for inhalers just by discovering and elimanating the allergen. One of the top allergins has been milk,cool aid and chocolate.


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