The Art and Science of Referrals

Referrals are a necessary part of optometric practice. Depending on what pathologies our patients bring with them through our front doors, referrals may be a daily occurrence. The nature of our practice settings can vary widely—from a private OD practice, to a combined MD/OD practice, a Veterans Affairs hospital, or a large academic university. Similarly, the capability, method, and efficiency of making referrals can vary greatly across these practice settings. Still, the core purpose of the referral remains the same—to seek care for the patient beyond the capability or expertise of our practice. Deciding when and to whom to refer requires a proper understanding of the art and science of the referral.

The Science

The step-by-step process of a comprehensive eye examination is taught in optometry school, practiced to proficiency in student clinics, tested in board examinations, and perfected daily through observation and experimentation. Depending on the outcomes of each test, decisions on diagnoses are made or eliminated as data are gathered. By the end of an examination, we have gathered enough information to formulate a list of differential diagnoses and our expectations for treatment and follow-up. It is at this point that the possible path forward diverges, depending on whether or not the treatment is something that you think you can handle or something for which you should refer the patient to another provider. In a study performed in Canada, there was a 9% referral rate to ophthalmologists from optometrists performing routine eye examinations.1
It may seem obvious that relevant clinical examination findings should be included in a referral letter, but an evaluation of incoming letters from optometrists in a glaucoma service found that 43% of the letters were considered “failures” because they did not convey the necessity and urgency of the referral. Of those failures, 26% did not include an optic nerve evaluation, and 6% did not include IOPs—essential findings in a glaucoma evaluation.2 Sending a record of the entire clinical examination in addition to a referral letter or practice-specific referral form is ideal.

The Art

The art of the referral comes in knowing the limits of your practice, accessing your network of trusted consultants, communicating with them effectively, and being an active participant in care. This is an aspect of our profession that cannot be taught in a step-by step-process; rather, it is one that must be cultivated, practiced, and challenged over a career of continuous learning.

Know Your Limits

Referring a patient to another optometrist, ophthalmologist, primary care physician, or other specialist necessitates reflection on the limitations of your practice as determined by the state board of optometry, the office itself, your clinical skills, and your knowledge base.

State-by-state scope of practice determines the need for some referrals. For example, in Massachusetts, ODs still cannot prescribe topical glaucoma medications. Availability of diagnostic instrumentation may require other referrals. If, for example, a patient with early age-related macular degeneration needs a macular OCT but your office does not have the equipment, a referral for diagnostic testing to an optometrist or ophthalmologist who has the technology would be necessary. If a patient with moderate glaucoma is noncompliant with topical medications, you may need to refer to a glaucoma specialist for a laser or surgical procedure to best manage his or her disease.

The decision to refer a patient should be done for a specific purpose. When you are deciding whether or not to refer, reflect on what information you are seeking and how the patient will benefit from an additional visit with a different provider.

Trust Your Consultants

ssembling an array of trusted colleagues requires time, effort, and, often, trial and error. In a study of a group of general physicians in Canada, Muzzin found that the providers were more likely to refer to someone they knew personally or had worked with side by side—in other words, someone they trusted based on proven ability.³ Other factors for referral included patient feedback and accessibility to care, including location and time to next appointment.³ “Test cases” were often sent to new physicians as a way to evaluate the potential for a referral relationship.³

I am more likely to refer a patient to a doctor from whom I consistently receive examination notes and correspondence. If I do not hear any feedback from a provider after several patients, I usually move on to another option.

Given the shift in ophthalmology to subspecialist training, it can be difficult to assemble a dream team of subspecialist physicians to whom you can consistently refer patients. Finding a practice of ophthalmologists with one or more subspecialties under the same roof can be ideal, as it ensures continuity of care. In a combined OD/MD practice, referring within the practice is convenient, but acquainting yourself with the management patterns of each MD in the practice can help identify patients who could remain within the practice and patients who should be referred to an outside provider.

Trust can be built in a referral relationship fairly quickly, but it can be destroyed just as easily if a lapse of judgement in care is detected, communication falls through the cracks, or patients consistently provide negative feedback.

Effective Communication

A letter addressing the concern and reason for referral, the relevant clinical findings, the urgency of the referral, your expectations for patient management, and any further follow-up arranged at your office should be included with your referral.

The reason for referral should be clear and concise and should include the clinical findings that support your thought process and validate your concern. The portion often left out of referral letters is the expectation for comanaging the patient: How do you want to manage care with the doctor to whom you are referring the patient? When is the patient scheduled to see you again? Be sure to include this information when you write referral letters.

An established protocol for how to handle referrals can be helpful. See Establish a Protocol for a few suggestions. The same courtesy letter should be extended for patients referred to you from a primary care doctor or an ophthalmologist.

Minimize Barriers

In a study conducted at Duke University, a focus group of primary care providers, nurse practitioners, and physician assistants were asked about barriers to referral to eye care professionals. The most frequent complaint was poor communication and the third most frequent was difficulty scheduling an appointment.⁴ In a hospital setting, in which an electronic health record system can automatically populate a letter to a referring doctor or nurse, these barriers can be easily traversed. In private practice, however, it can be more difficult to communicate with primary care providers due to a lack of information provided by the patient. It is important to institute methods of minimizing these barriers in your practice.

Ensure That Your Patients Receive The Care They Need

As optometrists, it is our challenge to blend the science and the art of our practice harmoniously to ensure that patients receive the care they need—even when it is outside of our practice pattern or capability. We can do this by performing thorough clinical examinations, networking effectively, and communicating clearly with the physicians to whom we refer about why we are concerned and how we think they can help.

1. Dobbelsteyn D, McKee K, Bearnes RD, Jayanetti SN, Persaud DD, Cruess AF. What percentage of patients presenting for routine eye examinations require referral for secondary care? A study of referrals from optometrists to ophthalmologists. Clin Exp Optom. 2015;98(3):214-217.
2. Scully ND, Chu L, Siriwardena D, Wormald R, Kotecha A. The quality of optometrists’ referral letters for glaucoma. Ophthalmic Physiol Opt. 2009;29(1):26-313.
3. Muzzin, LJ. Understanding the process of medical referral: Part 3: Trust and choice of consultant. Can Fam Physician. 1991;37:2576-2581.
4. Holley CD, Lee PP. Primary care provider views of the current referral-to-eye-care process: focus group results. Invest Ophthalmol Vis Sci. 2010;51(4):1866-1872.