The Art of the Referral Letter

One of the journals I skimmed through this weekend had a piece about Meaningful Use, which is Newspeak for what electronic medical records need to do in order to satisfy Federal requirements.

One of the requirements we must satisfy in the next round of Meaningful Use is to “send summary of care records in certain referral and transition of care situations”.

The Archives of Internal Medicine reported a year ago that 70% of primary care physicians claimed to inform specialists of patients’ medical history and the reason for consultation, while only about 35% of specialists reported to be getting this information.

I remember the eloquent referral letters I used to dictate years ago, when the administrative burden of a rural family practitioner was a fraction of what it is now:

        “Dear Mike,

         This is to introduce Mary Calderon, a 53-year-old Gravida 3, Para 2 with a BMI of 30 and a recent onset of postmenopausal bleeding 18 months after a seemingly normal menopause. Her ultrasound shows endometrial thickening….”


        “Dear Ned,        

         Thanks for seeing Bella Beaupre, an otherwise healthy 68-yar-old with six months of migratory polyarthralgias and an inconsistent laboratory profile. Clinically, she appears to have new onset of Rheumatoid Arthritis, but I would appreciate your help….”


After each consult, there would be an elegantly worded, impeccably typed letter on deliciously thick linen stationery, blue from Mike, cream colored from Ned, running a page or possibly two, signed with flair in ink with each one’s favorite fountain pen.

Just as my referral letter would state whether I wanted my specialist colleague to see the patient for a consultation so I could take it from there or simply take over and manage the patient, the consultation report would succinctly outline their thoughts and proposed treatment plan.

A few years ago, Mike’s group adopted an EMR and the two-page reports on blue linen stationery were replaced by five-page boilerplate reports that all tended to look very similar, to the point of making it hard to see what Mike really thought of the problem I had referred to him. The reports, even though he is a specialist, had smoking status, last pneumonia vaccination and all kinds of “primary care” information. Because Mike never learned to type worth a darn, his thoughts about each case I sent him were often reduced to just a line or two somewhere in the middle of each report.

My own referral letters have also lost some of their flair over the years. Instead of thoroughly summarizing each patient’s past medical history, somewhere along the line I started to focus on the problem for which I was referring the patient. I would have a catch phrase somewhat like “please see enclosed records for additional background information”. It was less satisfying, but it seemed there was never quite enough time to dictate one of those old, delicious doctor-to-doctor notes.

Now, with my own transition to electronic records, I can’t just pick up my handheld recorder and dictate a referral letter anymore. Anything written is the product of my own point-and-click or hunt-and-peck. By necessity, I now type a brief, yet to-the-point paragraph at the end of the office note about why I am requesting a consultation for my patient. It doesn’t say “Dear Mike” or “Dear Ned” anymore, and, just like Mike’s and Ned’s office notes, it has a lot of information that looks the same from patient to patient and visit to visit. But, after all, smoking status as a vital sign and all those other items are necessary to meet our current “Meaningful Use” requirements.

I haven’t asked either one of my colleagues how they feel about my referrals these days.

I, for one, really miss Mike’s thick, blue stationery and his wisely worded reports that always taught me something new or confirmed my own thoughts, signed with that broad nib fountain pen of his.

That was Meaningful Use, too.

2 Responses to “The Art of the Referral Letter”

  1. 1 Jewell Burke April 23, 2012 at 2:36 pm

    From a patients perspective, Doc tells you he will immediately fax your prescription to your local pharmacy. After a suitable time you call the pharmacy to be told they haven’t received his fax. Same thing for a couple more days! I call the office, punch numbers because I can’t speak to a live person. If I’m lucky, when I leave a message for his nurse, it will be called in. He says it was absolutely faxed and the pharmacy says they have not received it! This same fax deal often occurs with medical records as well. The Electronic Age of Improvement?

  2. 2 Jonathan Govette September 25, 2013 at 3:31 am

    That is why we are creating, we are getting rid of the fax machine once and for all for all healthcare professionals.

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