No matter what specialty you enter, at some point you will need to refer a patient to a different subspeciality, and even a different specialty.
Remember that you are referring the patient because you need additional guidance for patient care, whether it is for diagnosis, treatment options, or emergent care. You are not expected to know everything about the pathology for which you are referring the patient.
Here are some tips to help guide patient care effectively and efficiently and to help the referring doctor with the management.
Complete Documentation
A thorough history is crucial to understand the urgency of the disease process, which includes location, onset, and progression. This is especially important in the retina field which is often fraught with emergent add-ons.
However, a field defect due to a chronic retinal detachment that has been present for two months is not the same referral as one that started yesterday, even if the macula is attached!
Additional testing such as OCT, fundus photography and ultrasound images/interpretations are very helpful to establish an objective timeline of progression.
Complete Workup
A retina specialist will expect a full patient examination (with excellent refraction!) prior to referral. It’s not really appropriate to refer without a complete dilated examination because the retina specialist is “the expert.” This creates anxiety for the patient, as well as places the retina specialist in an uncomfortable position of having to explain why the referring doctor did not examine them completely.
Timely Referral
This can be challenging early in your career. Failing to recognize an urgent case such a retinal detachment, endophthalmitis, or a central retinal artery occlusion can have devastating consequences for patient outcomes.
These three conditions are typically not subtle diagnoses. However, there are variations that can be harder to recognize, such as a branch retinal artery occlusion (BRAO) with 20/20 vision. This is still an emergency and necessitates an urgent referral for a 2D ECHO and a carotid evaluation.
Other examples include management of diabetic retinopathy which may seem mild to moderate on examination. But without proper diagnostic testing including angiography, early retinal neovascularization (NVE) or severe ischemia may not be appreciated.
Continue to develop and refine your clinical skills in the examinations of all aspects of the eye that are not your specialty or subspecialty, and your examination skills will continue to improve so that you do not miss the more subtle diagnoses.
Strong Communication
Although a formal consultation letter is an absolute must for continuity of care, other forms of communication can greatly help build your referral base. Text messages for acute cases are often well-received and reflect your care and interest in both the patient and referring doctor. Exchanging fundus photos on smart phones not only gives great insight but establishes a personal communication line for further collaborations.
Patient Education
Remember that you are referring patients to a retina specialist to transfer their care to an expert in their condition.
Assure the patient that he/she is in good hands, but be careful of setting expectations that may differ from the retina specialist. For example, a patient with a macula on retinal detachment may not have surgery that same day, depending on numerous factors, or they may have a pneumatic retinopexy instead.
Patients with macular edema from different causes may not have an injection the same day due to insurance limitations. Be mindful that the decision-making is between a patient and the retina specialist.
General ophthalmologists play a vital role in the initial evaluation and management of eye conditions and will have retinal disorders that require treatment by a retina specialist. Close collaboration and effective communication between both sides are essential to ensure that patients receive timely and appropriate care for their retinal conditions.
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About the author: Geeta A. Lalchandani-Lalwani, MD, is a retina specialist and founder of Rocky Mountain Retina Associates in Boulder, Colo. After completing her medical degree from the MCP-Hahnemann School of Medicine, Drexel University, and ophthalmology residency at Case Western University. She received her medical and surgical vitreoretinal training at the Bascom Palmer Eye Institute, where she joined the faculty. Dr. Lalwani is president of the Vit-Buckle Society (VBS) as well as a member of the EnVision Summit program committee. |