Do GPs ever regret referrals?

Je ne regrette rien

Je ne regrette rien

An Australian study (featured today in Medical Observer) has found prostate cancer patients are more likely to regret surgery than radiotherapy. This had me wondering; if my patient regrets surgery, should I then regret having referred them to a surgeon?

We would like to think our referrals are always based solely on the best outcomes, but can we really claim, as Edith Piaf did, Je ne regrette rien?

Or are we in fact sometimes swayed by factors other than outcomes – things like tradition, familiarity, friendships, or yesterday’s guidelines? It’s hard to identify any one referral as adamantly wrong, particularly if we self-reflect through rose-coloured lenses. But surely not every decision can be all La vie en rose.

If a GP refers to a surgeon in the private sector, the patient usually ends up getting surgery. Something about hammers seeing everything as nails?

So, radiologists advise further radiology and pathology begets pathology. Sure, some private urologists routinely consider re-referral for radiotherapy, but many don’t. This, despite a recent high-quality study showing both produce similar prostate cancer outcomes*.

If my preferred surgeon routinely ignores radiotherapy (and perhaps my radiation oncologist ignores surgery), then the humble GP’s choice of referral makes all the difference to the patient’s treatment. Perhaps it ideally shouldn’t be our call. But in practice, it often works out that way.

It’s not so simple, of course – often the urology referral is for diagnostic biopsy, by which time the train has left the station. And access to a radiation oncologist may be difficult.

But it underlines the general concept that the GP’s role as gatekeeper occasionally involves deciding who to shut out.

We close the gate to help our patients all the time, of course. We barely need think about it for a clearly inappropriate referral, but often the decision is more nuanced, and no two GPs have precisely identical referral thresholds.

For incontinence, will we refer to the physiotherapist or gynaecologist? For mental health, the psychologist or psychiatrist? We make a judgement call based on which treatment modality we feel is best for our patient, taking into account the likelihood of the specialist using that particular modality.

For example, now we know arthroscopies for osteoarthritic knees are essentially unhelpful, do we have some sort of duty not to refer our ageing patient to a knee specialist who spent the last two years learning advanced arthroscopic skills in New York and has a new private practice to pay off?

In the rose-coloured world, the orthopod would keep their arthroscope sheathed, citing the latest evidence of ineffectiveness. But la vie is not always so rose.

Yes, it’s a fortunate referrer who can say they regret nothing.

* The NEJM study, 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer, showed that of around 550 prostate ca patients randomised to surgery and the same number to radiotherapy, after 10 years five died in the surgery group and four died in the radiotherapy group.

This article was originally published in Medical Observer, Oct 2016

About Dr Justin Coleman

Justin is a GP working in Aboriginal health in Brisbane, Australia. He is also a medical writer, editor and blogger. Further details at https://drjustincoleman.com/
This entry was posted in medical writing and tagged , , , . Bookmark the permalink.

4 Responses to Do GPs ever regret referrals?

  1. Thinus says:

    Reblogged this on Dr Thinus' musings and commented:
    A dilemma we (should) face daily

  2. I’m with Edith Piaf and can honestly say “Je ne regrette rien”. Are there things I would had done differently with the benefit of hindsight? Of course. Are there things I wish hadn’t happened? Desperately. Regret, however, is a very unhelpful emotion. It is much better to see these “mistakes” as learning/ growing opportunities.
    But this isn’t the point of your well-written and thought-proving blog, I know. Forgive my digression. The importance of “Choosing Wisely” when it comes to referrals, not just to investigation and prescribing choices, is an excellent one indeed, and one we need to be mindful of each and every time we decide on a management approach.
    Reblogged on https://genevieveyates.com/

  3. Pingback: Do GPs ever regret referrals? - Doctus Project

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s