Dermatology Referrals in an Academic Family Medicine Clinic
Background. Variations in referral rates among primary care physicians have implications for cost and quality of care, as well as primary care training. Dermatology referral rates of residents and faculty from an academic family medicine clinic are described.
Methods. Using a computerized referral tracking system, all dermatology referrals from January to March 1999 were retrospectively reviewed. Referral rates were calculated for individual providers, rates of uncompleted referrals were calculated, and reasons for referral were examined.
Results. Residents and faculty made 102 dermatology referrals during the study period. Although no significant differences occurred in referral rates between residents and faculty, significant variation occurred among individual providers. Junior residents had more uncompleted referrals (83%) than senior residents (29%) and faculty. Common skin conditions accounted for most referrals.
Conclusions. Wide variation exists in dermatology referral rates among family medicine residents and faculty. Moreover, many referral appointments are not kept. Family medicine training curricula should include formal education on the referral process.

The referral process is one of the most important functions of primary care. Through consultation and referral, primary care physicians help patients access expert opinion, diagnostic studies, or therapy. While they may improve the quality of patient care, referrals may also increase the cost of care. As a result, many health care delivery systems depend on the primary care provider acting as a "gatekeeper" of referrals to control costs.

Although previous work has described wide variation in referral rates among primary care providers, few studies have described referral rates of family medicine residents. A decade ago, Lawler observed differing rates among family medicine residents in the same residency program, though the rates were strongly affected by case-mix variation. Wu et al found that referrals made by resident physicians were less likely to be completed than those made by faculty physicians. Both of these findings underscore the observation that there is little formal training for resident physicians in the management of the referral process.

This study examined dermatology referrals from an academic family medicine center. Dermatology was chosen because it represents a fairly stable proportion of all referrals from our family medicine clinic. In addition, because skin problems tend to occur independently of other disease processes, there is less confounding of dermatology referrals by patient case-mix and comorbidity. Recent articles in the dermatologic literature have questioned primary care providers' abilities to provide appropriate care for skin diseases. This study served as a pilot study for a large-scale examination of referral rates but also sought to update previous work and provide insight into the origin of referral rate variations.