Thursday, 21 May 2015

Referrals – Inappropriate, Inconvenient or Unprofessional? (Easter egg - umbilical granuloma)

But first: why the hospital doctor who thinks that they have had an inappropriate referral probably has an educational need.

Every day, around the world, there is tutting by hospital doctors about the inappropriate referrals that they receive from primary care.   If we assume that both clinicians believe in good patient care and the best use of resources then someone must have an educational need for this situation to take place.  My question is: who has that need?

Let’s take a fictional yet real example: a baby with an umbilical granuloma.  The child has apparently been sent to the paediatric emergency department by the clinician who saw them in Primary Care.  The emergency department doctor sees the child, noting the inappropriate use of the ED to filter referrals from a GP.  They complain but accept their lot and assess the child but then send the child back to the GP.

Imagine that we could get the two clinicians to sit down and discuss what happened.  What the GP trainee who saw the child would say was that they thought that the child had an infection of their umbilicus, which they know to be a risk for sepsis in babies.  They tried to refer the child but they were passed back and forth between the paediatricians on call who said that this was a lump and therefore surgical, while the surgeons said that umbilical infections should be referred to the paediatricians.  In the end there was confusion and in the process both teams thought that the other had accepted it and the faxed letter from the GP never found an owner.

So the ED doctor might have been more sympathetic and less likely to say that the ‘referral’ was inappropriate when they found out that it was not a referral.  What the GP trainee might have learned is that umbilical granulomas often have a degree of discharge and look messy but that doesn’t equal infection.  They may have been interested to know that many clinicians are adopting a ‘leave it alone’ approach to umbilical granulomas since they have a natural tendency to resolve. (1) Some advocate hypertonic saline (2) as a topical treatment but ultimately if left alone, these unsightly lumps will go away if you ignore them for long enough.  Most will welcome the move away from the game of ‘hit the moving target with a silver nitrate stick’ while hoping that there is no accidental application onto healthy skin.

Lets hope that the joint RCPCH and RCGP document 'Facing the Future Together' with its 11 recommendations will provide an impetus for better communication between primary and secondary care.  I am particularly hopeful that point 4 becomes a reality because educational meetings can work both ways.

Facing the Future together: The first four standards-

So whenever something seems ‘inappropriate’, it may be a misunderstanding or there may be a genuine opportunity to share something between two professionals.  I accept that there are GPs who don’t care about inconveniencing patients or overloading their local emergency department but these are a vanishingly rare breed.  More often, if I get in touch to clear something up that is exactly what happens and I am just as likely to be the one set straight.  The important thing is to talk to each other and not about each other.  That really would be inappropriate.

Edward Snelson
Naturalised Citizen of the People's Republic of South Yorkshire
@sailordoctor #GPpaedsTips

Easter egg - for more on umbilical granuloma follow the links below

  1. Umbilical granulomas: a randomised controlled trial J Daniels, F Craig, R Wajed, M Meates Arch Dis Child Fetal Neonatal Ed 88:F257 doi:10.1136/fn.88.3.F257

  2.  BANGLADESH J CHILD HEALTH 2010; VOL 34 (3): 99-102 Therapeutic Effect of Common Salt (Table/ Cooking Salt) on Umbilical Granuloma in Infants AKM ZAHID HOSSAIN, GAZI ZAHIRUL HASAN, KM DIDARUL ISLAM

Disclaimer: All the opinions expressed here are someone else's.


  1. Hi Ed

    Great post thanks
    I would add that the GP trainee should have discussed this with their trainer or other supervising GP So the learning need may be for that doctor
    If they hadn't discussed it then perhaps the training practice needs to look at its supervision system


    PS I am SO pleased we don't treat these with silver nitrate anymore!

    Alan Shirley
    GP, GP trainer, TPD for GP & BBT

  2. Thanks for your comment Alan. I would also hope that the GP trainee would discuss this if they were unsure. I know that GP trainees are generally very well supported and can always ask including, if they want it, their local paediatrician. Phone advice is often underutilised.
    The case here illustrates what can happen if 2+2 doesn't really equal 4. There are times when I've extrapolated a rule and made a false conclusion. We ask when we think we don't know. My fear is that so much of what we don't know is never reported back to us because our colleagues think that we are too arrogant or set in our ways to hear about it. I want to know!

  3. These are all common cognitive mistakes that we are all subject to in general practice.NHS is growing up alongside with the team working attitude consistently, but within the areas of general practice there is still a blame culture and that may contribute significantly to the constant tutting of wrong referrals and 'time not well spent'.I believe it's all about the people and the educators' skills to prevent the 'Dunning–Kruger effect (–Kruger_effect) that is often encountered, paradoxically, in more experienced clinicians.

  4. Thanks Veronika. Well said. You have summed up nicely what happens when two clinicians have a mismatch in confidence or knowledge. If a referral seems "wrong", ask for more information. If there is a discussion to be had about doing things differently, have that discussion. There's no real value in the expression of disapproval and it deepens the primary-secondary care professional divide. The referee must respect the referrer enough to contact them to discuss any perceived problem and the referrer should be interested in the possibility that change is needed. It is a big ask for both sides considering what we are all used to though.