How to undertake the best referral
Writing a letter to your GP about your patient is not just a skill but a requirement. An effective referral letter from you to the GP can open doors for both patient and yourself. I set out to discuss the process with clinical colleagues.
Taught as a student, it was part of my expectation to have letters typed for me when I hit the big wide world. You can imagine my surprise when I first joined Northampton Area Health Authority in 1978 to learn that no such secretarial support existed. Only managers had secretarial support. I covered the story of letter writing in my book ‘Podiatrist on a Mission’ which ended with meeting my future wife 41 years ago. Typed letters on formal typewriters are far removed from today’s values where self-typing on PCs is the norm. We have well-established communication systems, with all podiatrists expected to be computer literate. My colleague and I dictated over 40-60 letters daily to our full-time secretary to update GP practices, but this was 15 years later. This covered our diagnosis, treatment and actions required. When I first took my consultant’s post, I found that GPs deferred to us over many matters to do with feet. Letters crossed my desk from every conceivable source. On one occasion a senior colleague, one older and ideally experienced had written a letter. I glanced at the typed epistle and was unsettled.
The less acceptable letter
‘Dear Dr Abc,
I saw your patient today who had an ingrown toenail and think they should have nail surgery. Are there any medical concerns that would prevent me from proceeding…’
Many reading this sample may feel this is both reasonable and sensible. But reflect more carefully on the content and presentation. A podiatrist is trained to undertake nail surgery as part of their standard education. A GP refers a patient to a service expecting that all due care is taken to provide such a service. Today this also includes providing drugs that avoid tapping into the GP’s budget. Because the topic of prescribing will complicate the theme of letter writing this will be left for another article. Taking a medical history precludes all risks in connection with nail surgery. If the podiatrist cannot offer this service, the letter should recommend deferment elsewhere. In all other cases assess the patient and get on and provide the treatment you were trained for and expected within your role as an independent practitioner.
Acceptable engagement when writing to a GP
Of course, there are exceptions to the rule and it would be churlish of me to say there were times when I felt there were no risks that needed advice. Through years of practice, my confidence and experience changed to reflect my own learning. However a professional needs to write a letter in such a way that looks it looks competent, professional, ethical and helpful. If you seek advice, there are ways to achieve this and certainly ways to avoid looking as if you were poorly informed. Like many, I learned the hard way, made mistakes, and almost certainly wrote the type of letter my colleague had when first qualifying. Today the above example falls fair and square into the rule ‘avoid!’
‘Dear Dr Abc,
I saw your patient today. I have recommended nail surgery and have covered all the important risks covering healing, regrowth, potential pain and infection and he wishes me to proceed. From the history and examination, he appears healthy without medical concerns. An information sheet has been provided to support the planned treatment. I will keep you informed of progress…’
The second letter is more professional and tells the GP that you are a competent professional. Of course, more could be added as a diagnosis. Make headings, and provide a list of medical issues and drugs used. You can add more about your assessment including vascular flow analysis (doppler). Your clinical notes will carry all the details showing that you took detailed care. It is good practice to copy the letter to your patient. Communication is enhanced and there is an opportunity to correct any misunderstandings. Never write anything you would not wish the patient to read and be aware, that GPs copy letters are copied to patients. Never make any kind of judgment in a letter that could later lead to embarrassment.
Write to a doctor about your patient with concerns
A patient presented with an ingrown toenail and was having chemotherapy. In this case, an oncologist was involved. The protocol requires you to write to the consultant and copy the GP. The patient’s doctor needs to be aware of any treatment they may wish to perform. Chemotherapy lowers the blood cells, particularly white cells, so fighting off infection immediately becomes a problem. The GP is the wrong person to write to for advice because should something arise through any misunderstanding, the GP will rightly turn around and say that you were the professional performing that treatment, not me. With modern MDT practices, management is better coordinated than it was once when shared as teams. An oncologist will rant if you try to undertake a phenolisation during the height of cancer management. I am not making this stuff up as I had one oncologist write back and say.
‘DON’T DO ANYTHING – YOU WILL KILL THE PATIENT!’
This type of response you never forget. But how do you manage a letter? Again it is important to be cognisant of the medicine.
‘Dear Dr Xyz
Your patient has an ingrown nail. I am managing this conservatively to avoid any healing or infection issues but at some stage, I would advise that she is referred/managed by non-phenolisation to remove the chronic inflammation by surgical excision. If she continues to have repeat infections this will pose additional risks when she has her next course of chemotherapy. We can minimise any risk with antibiotics until she has healed. However, it is unclear when you wish to start the next treatment cycle. If you could liaise with me on this matter that would be of considerable help. etc…’
This letter is informative, confirms that you know what you are talking about and begs liaison so the patient has collaborative support.
Writing to a GP requesting medication
There is a strong advocation to persuade all podiatrists to consider independent prescribing. Whether in the NHS or independent practice, management comes under the podiatrist’s control. If a GP provides a drug, he or she is doing this by proxy and many doctors are no longer happy at taking such risks. Over-the-counter medicines will help most but baseline drugs like antibiotics should be part and parcel of modern podiatry practice. There are drugs that are not covered. So how do you proceed?
Again, purely through experience, I learned the ideal form of a letter to help a patient. I read a colleague’s letter. He was a consultant anaesthetist and pain specialist. As this was a case of independent non-NHS treatment he wrote along the following lines.
‘Dear Dr Albe-Well
Diagnosis…. etc
Your patient presents with ongoing ankle pain due to XYZ and I have advised and undertaken ABC investigations today and attached the relevant reports. I would recommend that you consider introducing gabapentin 300mg tds initially. I have arranged to see her in three weeks…’
In the NHS, drug protocols should allow you to provide treatment around your scope. In the independent sector, patients can pay legitimately as part of their non-NHS management. Your letter may have a rider that indicates that the medication you recommend is not listed for sale or access and you appreciate following the recommendation. These concerns are only included to highlight some of the issues podiatrists may face. Please refer to The Royal College of Podiatry or Institute of Chiropodists & Podiatrists for information about the use of independent prescribing and access to drugs and medicines. Courses such as webinars and branch talks on prescribing are constantly run at conferences.
Writing to a GP when you want an urgent referral onwards
In all probability, this aspect of letter writing is the most vexing. Both from Facebook and from interviewing over the year, some podiatrists have found their letters have fallen on deaf ears! The question must be why? The first thing anyone must do is to ask if the letter is clear enough? Here are a few things you need to know about doctors.
- Doctors are busy, meaning they have a mass of correspondence to get through daily.
- Scan reading means it is easy to miss actions, and actions are what you want to happen.
- Long letters and those on A4 paper have been the GP’s least favourite missive. A4 has to be folded if the system uses the Lloyd George-style envelopes. Today we are more likely to see information generated via e-mail and computer systems. However, these systems lie in the domain of the NHS. Links to the independent podiatry practice are unlikely unless the practice dovetails with the GP centre.
Call to action
- The heading must be clear about what is needed so the action flies off the page (virtual or otherwise).
- Highlight the history clearly in a logical way.
- Be clear about what you want the doctor to do.
One example on Facebook comes to mind. Diagnosed as neuro-vascular corn mimicking a verruca (VP) the podiatrist rightly knew and indeed wanted to refer the patient. The history from the FB post suggested an ‘inclusion cyst’. The post went like this…
The problem
“This was a 40-year-old ICU nurse with a 2/12 history of pain. Her medical health is unremarkable. Describes pain as burning sharp pain like she’s standing on a needle. Went to the emergency clinic due to unbearable pain – no fractures. She’s been treating it as a verucca – and from the picture, it looks like one. She’s tried all the OTC (Over-the-counter) treatments (and self-debrided) and has been occluding it with duct tape for the past 3 weeks but the pain has worsened. I saw her yesterday and debrided the lesion – the skin was very macerated but it no longer looks like a verucca. More an HD similar to those you’d see in a smoker. I offloaded it for her – a temporary fix just to alleviate her pain but the minute she put her foot on the floor, she described a sharp burning pain like a needle running all the way from her foot up her neck. I’m puzzled. What can others suggest? The pain she describes suggests a neurological involvement. Write to GP requesting ultrasound. Refer on for needling? The picture is debridement – it does look like a verucca there but not at all during debridement. I just want to help this poor woman and reduce her pain!”
The task
Too painful to debride, neurological involvement? Treatment had been disappointing for a VP. The podiatrist is requesting advice from colleagues and thinking along the lines of an ultrasound (sonographic imaging). The Facebook post was a responsible and a good example of a common enough problem. Outside an average practice’s range, the condition requires a referral. However, the condition is also outside a general practitioner’s range. Investigations are required as the diagnosis is predicated on initially ruling out any conditions requiring surgery. Could cautery, microwave, or cryotherapy be considered? In this case, I would send the referral directly to the specialist but that will depend upon your network in the independent sector and protocol in the NHS.
When a letter to the GP or to a specialist is required
This letter assumes you have sent a referral to the GP rather than the specialist, but similarly, you can send the same format to anyone.
Dear … Name, DoB…
Diagnosis: presumptive inclusion cyst
Medication: Contraceptive pill. No allergies declare
Medical History: Unremarkable Occupation: ICU nurse. History No injury admitted.
Main complaint: History of the pain for 2 months associated with a mass under the right foot. X-ray was taken at the emergency clinic. Fracture excluded. Treatment today consisted of local conservative local application and offloading, which failed to resolve her symptoms.
Examination: an intractable plantar keratoma is apparent with a non-bleeding vascular mass located between 2 and 3rd metatarsal head. Non-crater formation, but capsulated and appearance of basal layer damage with cross-infection typical of papillomavirus. There is no evidence of bacterial infection although underlying abscess or aseptic deeper tissue formations cannot always be excluded. Vascular and neurological status is intact and her skin and nails otherwise normal.
Action & advice: Pain increasing on weight-bearing. Inclusion cyst suspected due to foreign body? Malignancy risk – low. Mobility significantly affected and occupation. Sensitive to touch and debridement. This does not appear to have the characteristics of a true corn or verruca and requires investigation. Potential surgical management and histology. Referral to a podiatric or orthopaedic foot surgeon is recommended.
Final analysis
The letter is A4 and should have a professional heading. The length is 181 words. Headings are highlighted so the reader can pick up on the diagnosis, action, and advice. The format is consistent with many medical reports although different layouts will vary. I do not favour the SOAP method layout but that is for the clinician to decide. The content and confident command of medical assessment are important, not the fact that you cannot do more. Bear in mind, that the average GP does not want the responsibility of tackling something they might have problems with. The terminology carries some heavy impact terms. ‘Malignancy’ you don’t know but the risk is not high on balance. This will trigger GP concerns. Check out my consultation and request. Non-bleeding vascular mass is also a controversial term and can the GP risk not following your advice?
Follow up
Make sure the patient has a copy and direct them to the GP to consolidate your referral and recommendations. This should be noted in your records. Follow this up after the patient has attended. If you do not develop feedback, you cannot hope to reflect upon your success or shortfalls.
Imaging support
Independent practitioners should consider engaging in an imaging service as part of their management. This means that diagnosis can be fine-tuned. Ultrasound imaging would be recommended together with a 2-view X-ray. Practices should comply with IRMER and apply to either NHS or local private facilities based on convenience to their patients to acquire a rapid diagnosis. A radiologist could then insert the information and report into the referral letter to help expedite and triage the patient. In my experience, such a referral gains swifter action and is usually copied on completely to the consultant while the GP practice backs off trying to dispense some useless drug regime delaying treatment for the patient. This patient’s occupation would benefit from the earliest intervention, as she would be a first-line worker during the Covid-19 crisis.
This was a real case reported on Facebook. If you have a query about practice, do write to me in confidence – no names, no judgement, just advice based on experience and research. This opinion is based on my interpretation of the information provided. And, remember I have made most of the mistakes I advise against making. Contact busypencilcasecfp@gmail.com or make a comment below if you want to share.
David was a former consultant podiatric surgeon, clinical tutor and lead clinician working in the NHS and Independent sector until 2018. He has 43 years of experience in the field of podiatry.
Thanks for reading ‘Writing to a GP about your patient’ by David R Tollafield
Why not read one of the only autobiographies written about podiatry from the same author? Now available from Amazon books.
Published by Busypencilcase Reflective Communications Est. 2015
Released 1 June 2021
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