oa South African Family Practice - Why doctors do not answer referral letters : original research
Background: Healthcare workers at primary healthcare (PHC) clinics are frustrated by the fact that they do not receive replies to their referral letters to doctors. Referral letters act as permission slips to allow patients easy access to treatment by specialists at secondary and tertiary service levels and communicate reasons for referral. Reply to the referral letter is vital for continuity of care to be maintained and to enable comprehensive recording at PHC level. It has been found that poor feedback leads to poor follow-up care in the PHC setting. Previous research has investigated the influence of the method of communication, either by use of pro forma letters or by electronic feedback on answers. The study on which this article is based endeavoured to understand the receiving doctors' reasons for not replying to referral letters and the context contributing to this problem. If this matter could be resolved it would relieve frustration at PHC level and improve healthcare services in future.
Methods: A qualitative study method was used, as the purpose of this study was to understand and explore in depth doctors' context, perceptions and motivation for not answering referral letters. In-depth interviews were conducted with six purposefully selected doctors who all had more than one year's experience in their different departments. The exploratory question posed was: ''What factors are contributing to not replying to referrals from primary healthcare clinics?'' Interviews were tape-recorded and transcribed verbatim. Themes were identified using the Tesch method. Analysis was done independently by two coders, who afterwards reached consensus on identified themes. After analysis of each interview, reliability was further ensured by going back to the participants to verify that the interpretation represents an accurate description of the participant's view.
Results: The participants included one consultant and five registrars with between 18 months and 8 years' experience in their departments. According to participants, many reasons contributed to their not writing answers to referrals. The reasons for not replying to referral letters pertained to the working situation at the referral hospital and factors regarding the referrals themselves on the one hand and the hospital doctor's perceptions as to his / her role in the healthcare system and his / her perception that it is futile to answer referrals on the other.
Conclusions: There were multiple reasons for doctors not replying to referral letters. The referring personnel can address some of these reasons by ensuring accurate referrals on appropriate days, considering style preferences of the hospital doctors and by the use of pro forma letters. Hospital consultants can address other factors by giving attention to the socialisation of their juniors and by adjusting the referral system so that it does not rely on patients to courier letters. Further research needs to be undertaken in South Africa to assess the influence of various methods of communication in the referral system as regards the quality of communication between different levels of care.
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