Referrals – are we having too much of them?


Working in my hospital, the national dumping referral center in Malaysia, making and receiving referrals are quite a norm. As a houseman, I don’t personally accept referrals, but I have to keep making them. Now that I work in A&E, I have no choice but to refer, refer and refer.

Why do we refer in the first place? We refer a patient when we can’t manage the case further. For example, we refer to surgeons for intraabdominal injury because you can’t expect an emergency physician to perform laparotomy. We refer to neurosurgery for intracranial bleeding. We refer ortho for irreducible fractures. Sometimes we refer to get a specialized-care beds for example we refer to Coronary Care Unit (CCU) for myocardial infractions, we refer ICU for intubated patients. The MOs in charge will always say their beds are full, but we have to refer anyway.

Are doctors becoming more like postman, referring patients here and there?

And sometimes we refer just because the MOs are afraid of medicolegal issues that may arise. This is the most annoying kind. In a tertiary hospital like mine, everybody is uptight, everybody wants to save their own arse. Almost every case needs referrals, although sometimes it is not even necessary because even a mediocre house officer like me knows how to manage it. Due to an overwhelming amount of referrals, some MOs become very apprehensive while taking referral calls. They become fierce tigers, shouting to the person who’s referring to them, due to the nonstop referrals.

Me, I don’t like to refer patients unless very necessary. But being a house officer, I have no choice but to comply to this annoying system that I am stuck into. Imagine, a gynecology MO wants me to refer a patient for a simple pneumonia. Come on, even med students know how to treat pneumonia! Ortho MOs referring medical for sepsis, only in my hospital. In other hospital, ortho MOs handle the sepsis. I hate most referring to surgery because they always want to know the FBC, ABG, RP, PT INR, CXR, AXR and all other  investigations in the world. Come on, if it’s a clear cut intraabdominal injury with hypovolemic shock, why do you need a Hb for? If there’s a big fat abscess at the flank of that old lady, why do you need a white cell count for? Yes, you might need all that investigations later, but can’t you see the patients first before the results come back?

Sometimes I have to resort to lying to the MO I am referring to because I have to get them see my patients. Else, my work is considered unfinished. I can be considered as committing a malpractice for negligence, failure to refer.

There was one polytrauma case with intracranial bleed and long bone fracture, the patient was chest tubed and intubated. We refered neurosurgery as the primary team for the intracranial bleed and refered ortho for the long bone fracture. But I was scolded by SISTER (not a doctor) for not refering to surgery. Reason? I have to notify the surgeons when there’s a chest tube, in case the primary team wants to take the chest tube out. Come on! I am sure neurosurgery can take out the chest tube when they need to.

Do we need to refer to surgery to TAKE OFF the chest tube? Seriously??

Seriously what kind of stupidity have I stepped into? Must every patient be refered? That’s why we see KL patients are very spoilt. Spoilt in sense of medical care, too many doctors from many specialties (sometimes unnecessary ones) treating one individual patient! In this case, patient care is fragmented and not unified. Spoilt also as in spoiled brat. Patients are manja demanding everything to doctors, sometimes even demanding to be referred when there’s no indication for referral.

My MO who worked in Sabah before transferred to KL, feels very stressed and depressed, because in KL he can’t treat his own patients. He said that he becomes like a postman, writing referrals and send patients off to the specialist clinic.

Although I am glad that I learn a few things or two referring patients, I feel that I am not doing any active treatment for the patients. I’d gladly get out of this hospital to go somewhere with less specialties so that I can treat patients on my own. I am not saying I am very clever to treat all kinds of patients, but at some point, I really have to start learning how to treat them. I have to quit being a spoiled-brat doctor who must refer every patients I see.

If I’m kicked out to Borneo’s district hospitals, I really need to manage patients on my own, rather than referring and referring.

3 thoughts on “Referrals – are we having too much of them?

  1. You really worry me if you’re thinking of coming over to Borneo where quite frankly. I wouldn’t want you for a colleague. You seem very small minded for a start, and quite arrogant for someone so junior, bottom rung of the ladder HO-MO. Where do you get off questioning your MOs/Specialists when they ask you to refer cases to other departments? That’s your job! Show some respect and trust that they MAY know just a little bit more than you having had more experience in managing cases. Do you have so little understanding of specialities and what they represent? In your opinion, having your small brain treating one patient with multiple illnesses is better than having the relevant specialists aide you, is it? How very arrogant of you, ignorant fool. Please, do the “poor” people in Borneo a favour and stay put in the West where at least your irresponsible attitude won’t kill us off. And please trust, moving to some district hospital in Borneo won’t solve your problems. You should know that people here are 10-fold more educated now, in some cases more so than in the West..so if you do anything wrong, you’re gonna get sued..even if it is by an orang Kampung. Don’t think orang kampungs can’t spot a fraud doctor who knows nothing.

    • Well alhamdulillah for past 2 years as a humble houseman i run every single patient by my seniors. And i have not killed anybody yet. I also have learnt that better to be scolded for referring than not to refer at all. Although i dont like it, it doesnt seem that i have a choice. Referral is nothing new to me as a houseman. It surely wont be a problm for me as MO.

      My pea size brain hasnt killed anybody yet, doctor. Unlike one of the surgery mo who insist that an unstable intraab patient go to CT and bleed to death. But hey, nothing is better than name-calling and criticizing another junior doctor isnt it? Very surgeon-like and my strong guess is that you are in that department.

      Where i get posted next is not your business doctor. And you worrying about me being in borneo is not my problem. I love my job and i am professional, although i am still learning. If you think i am arrogant, thats up to you. Not my responsibility to change your mindset.

      Finally, take it easy doc. Wherever you work has probably worn you out till you have to resort to name calling this blessed syawal. Selamat hari raya.

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