General Practitioners' Perspectives on Barriers to Communication With Specialists in the Referral System: A Systematic Review and Meta‐Synthesis

ABSTRACT

Background and Aims

For achieving an effective integrated primary health care, communication between healthcare providers is a key element. This study aimed to identify general practitioners' reported barriers to communication within referral systems and propose actionable strategies for improvement.

Methods

Guided by PRISMA 2020 guidelines, 22 qualitative studies from PubMed, Web of Science, Scopus, and ProQuest were analyzed using inductive thematic synthesis. Quality assessment followed Standards for Reporting Qualitative Research (SRQR) criteria.

Results

Four central themes emerged: structural barriers (subthemes: inefficient health system, shortages in the number of specialists and heavy workload), regulatory and procedural barriers (subthemes: lack of comprehensive communication protocols, unclear delineation of roles and responsibilities, inadequate economic incentives, lack of continuity between providers, lack of interest in specialists, time consuming communication process), technological barriers (subthemes: ineffective methods for communication, challenges in using electronic medical records), and personal and interpersonal barriers (subthemes: having different approaches to healthcare, inappropriate specialists' perceptions of general practitioners' roles, lack of professional trust and respect, social anxiety disorder in the workplace).

Conclusion

Health policymakers must prioritize structural and procedural reforms, including standardized communication frameworks, interoperable digital infrastructure, and interprofessional training programs. Addressing these gaps can enhance referral system efficiency, reduce diagnostic delays, and strengthen health system resilience, particularly in low‐resource settings.

Trial Registration

The protocol of the review was registered in the International Prospective Register of Systematic Reviews (PROSPERO) on December 20, 2023 (Supporting Information S1).

Summary

• Support from health organizations and national health policymakers is necessary to build strength and resistance in the health system to improve communication between general practitioners and specialists.

• Enhancing the role of telemedicine, which includes electronic consultation tools and virtual care, is another important factor in improving communication between general practitioners and specialists.

• Establishing nonpunitive and non‐judgmental feedback in the referral system leads to better communication between general practitioners and specialists.

Abbreviations

EMR

electronic medical record

GPs

general practitioners

PHC

primary healthcare system

PRISMA

preferred reporting items for systematic reviews and meta‐analyses

PROSPERO

international prospective register of systematic reviews

SRQR

standards reporting qualitative research

1. Introduction

In this condition, to improve performance, General practitioners (GPs) in any primary healthcare system (PHC) play a vital role as the first point of contact of patients, and their function is to maintain different types of medical care [1]. Receiving advice from human sources is very important for them when they want to reach an accurate diagnosis, referral decision and patient management, and most of the time, research papers or text books are not enough to answer their questions and obtain the information they need; as a result, they need scientific support, confirmation, and receiving feedback [2]. In this regard, the interaction between them and specialists in providing effective primary healthcare is undeniable [3].

Currently, if any health system tends to achieve effective integrated care, communication between healthcare providers is a key element [4]. Inaccurate communication between GPs and specialists can lead to poor follow‐up care, considerable implications for quality of patient care, poor patient safety, patient dissatisfaction, and lack of continuity of care [5, 6]. Furthermore, unsuitable communication creates an unhealthy work environment for both GPs and specialists and may result in diagnosis failure, inaccurate treatment, adverse drug reactions, and poor health outcomes [7].

On the other hand, cross‐sectoral communication that provides a teamwork environment between GPs and specialists can enhance the quality of medical interventions and has many benefits for patients [5]. Although, in many countries, especially in developed countries, the use of cutting‐edge technologies facilitates communication between health providers within electronic medical records (EMRs), this process is complex and has many challenges for users. For example, difficulty and incompatibility could exist in accessing patients' information and sharing medical responsibility. In addition, technology cannot guarantee effective personal interaction, which is a vitally important factor in creating a collaborative atmosphere in communication between GPs and specialists [8, 9].

Moreover, GPs, as key decision‐makers in any referral process, influence access to PHC and can improve the utilization of health services in underserved, remote, and other areas; therefore, any health system should consider their perspectives to overcome these problems [10]. For these reasons, the objectives of this study were to answer two questions: (a) what are the perspectives of GPs on the barriers to communication with specialists in the referral system? and (b) What can any health system do to overcome these obstacles and create effective collaboration between GPs and specialists?

2. Methods

2.1. Design

To achieve the objectives of this study, our team used the PRISMA 2020 guidelines [11] to conduct this systematic review and meta‐synthesis. In addition, for analysing the data, Thomas and Harden's suggested method was used [12, 13]. We performed three steps, including creating codes, designing descriptive subthemes, and finalizing analytical themes, in this study. Furthermore, we received and checked all the constructive suggestions of academic counsellors to ensure the applicability of the results of this meta‐synthesis.

2.2. Search Strategy

In April 2024, we started this systematic review and meta‐synthesis. We used four electronic databases: PubMed, Web of Science, ProQuest, and Scopus. With the help of our librarian team, we finalized our search strategy: (“medical doctor” OR “general practitioner” OR “physician” OR “family physician” OR “doctor” OR “family doctor” OR “family practitioner”) AND (“communication” OR “connection” OR “contact” OR “correspondence” OR “correlation” OR “relevance” OR “linkage” OR “teamwork” OR “partnership”) AND (“specialist” OR “anesthesiologist” OR “cardiologist” OR “dermatologist” OR “endocrinologist” OR “gynecologist” OR “hematologist” OR “neurologist” OR “obstetrician” OR “oncologist” OR “ophthalmologist” OR “orthopedist” OR “pathologist” OR “otolaryngologist” OR “pediatrician” OR “psychiatrist” OR “radiologist” OR “surgeon”) AND (“primary health care” OR “primary healthcare” OR “primary care” OR “primary medical care” OR “basic health‐care” OR “primary health‐care” OR “initial care” OR “referral system”) OR (“barrier” OR “block” OR “obstacle” OR “stoppage” OR “problem” OR “hardship” OR “rigor” OR “severity” OR “hardness” OR “difficulty” OR “trouble” OR “discomfort” OR “obstruction” OR “complication”).

With a manual search in key journals and gray literature, multidisciplinary electronic databases, and forward and backwards reference tracing of extracted articles, we finalized the search step. The limitation of the publication date was from the beginning to the time of our search (April 2024). In addition, EndNote software 21 (Thomson Reuters, Philadelphia, PA, USA) was used to import the results of our search on the internet.

2.3. The Eligibility Criteria

We included all studies concerning the barriers of communication with specialists in the referral system from the perspective of GPs. Because meta‐synthesis strives to synthesize findings from multiple qualitative studies that, while distinct, share thematic or contextual connections [14], articles that used qualitative methods and were published in English until April 2024 were included. We excluded studies using quantitative methods, not relating to barriers of communication between GPs and specialists, from the perspective of GPs.

2.4. Study Selection

First, duplicate data were removed by using EndNote software 21. Then, two reviewers (H.F. and F.G.) independently reviewed the headings of the articles. We included all studies from the perspective of GPs on the relationship between GPs and specialists in the referral system. Before the full‐text review, to identify the final included studies and classify the excluded articles, we performed an abstract review with a focus on the inclusion and exclusion criteria. After a full‐text review, specific articles were identified. Moreover, to identify any additional related studies, a cross‐search was performed on the references of the included studies.

2.5. Quality Appraisal

Three researchers assessed the included studies (H.F., F.G., and A.F.). Checking the quality of the studies to debate the conclusions and results of the articles and to judge the integrity of the data is a vitally important factor in the approach of qualitative reviews [15]. The Standards for Reporting Qualitative Research (SRQR) [16] criteria were used to assess the quality of the publications. Since there is no agreement concerning the role of the qualitative assessment of studies, in this review, we did not exclude any articles from the synthesis [17]. However, a number of high‐quality articles appeared to play a substantial role in qualitative synthesis [18].

2.6. Data Extraction

We extracted and tabulated the included studies by rereading the selected articles, including demographics of participants, attributes of the articles, and details of any outstanding future. A.S. and A.F. performed the data extraction, and each study was assessed by defined criteria in the SRQR in terms of methodological coherence.

2.7. Qualitative Data Synthesis

The qualitative synthesis method of Thomas and Harden was used in this review [12]. This method focuses on developing themes inductively from the data of the articles. The MAXQDA V.18 software was used for qualitative synthesis. Synthesis started with a consummate reading of each study's full texts, after which we performed a rereading. After that, three researchers (F.G., A.F., and H.F.) synthesized and extracted any articles by coding the text of the results and discussing the results independently and line‐by‐line. The synthesis process continued until we could not find a new subtheme (when the saturation point was reached). To access robust and clear data, triangulation of synthesis and data sources was performed. This process involved three independent syntheses and regular meetings with our team to discuss the findings [19].

The findings of the three independent syntheses were debated and compared at the meetings, and finally, themes were developed. Furthermore, the translation phase involved comparing and collecting the themes recognized by the synthesis of each study to maintain the key themes, reaching similar ideas in the different studies and developing pervasive ideas about the research questions.

3. Results

3.1. Study Selection

Using our designed search strategy in four electronic databases, we found 4446 publications concerning the barriers to communication with specialists. Before reviewing publications by title and abstract, 539 duplicate articles were removed. In the title and abstract review step, we excluded 4359 publications, and 87 articles remained for the full‐text review step. After full‐text review, 65 articles did not meet the inclusion and exclusion criteria. Most of the articles were excluded for two main reasons: they were not related to the scope of this study (n = 29) and they did not include a related or identified sample (n = 17). Finally, after excluding articles from the full‐text review step, 22 studies were included [20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41]. The process of finding related studies is shown in Figure 1 in detail.

Figure 1.

Flow diagram showing the different phases of searching for relevant publications.

3.2. Results of the Assessment of the Methodological Quality

The 22 articles that were included in this study were assessed critically by three authors. “Researcher characteristics and reflexivity”, “Techniques to enhance trustworthiness”, and “Ethics pertaining to subject's human” reported poorer results than other SRQR items. Four articles received full scores [32, 37, 40, 41], and the lowest score for an article was 14 out of 21 [30].

The required information regarding the scoring process is shown in Table 1. Overall, the included studies in the assessment phase provided rich data for synthesis. Nevertheless, the nature of weak scoring items was considered in the synthesis process, which contained potential biases in any article.

Table 1.

SRQR critical appraisal tool results for qualitative studies.

Study	Title and abstract		Introduction		Methods											Results/findings		Discussion		Others		Score
	Title	Abstract	Problem formation	Purpose or research question	Qualitative approach and research paradigm	Researcher characteristics and reflexivity	Context	Sampling strategy	Ethics pertaining to subject's human	Data collection methods	Collection instruments and tech	Units of study	Data processing	Data analysis	Techniques to enhance trustworthiness	Synthesis and interpretation	Links to empirical data	Integration with prior work, transferability	Limitations	Conflict of interest	Funding	Out of a possible 21
	S1	S2	S3	S4	S5	S6	S7	S8	S9	S10	S11	S12	S13	S14	S15	S16	S17	S18	S19	S20	S21
Berendsen et al. [20]	×	×	×	×	×	×	×	×		×	×	×	×	×		×	×	×	×	×	×	19
Stille et al. [21]	×	×	×	×	×		×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	20
Easley et al. [22]	×	×	×	×	×		×	×	×	×	×	×	×			×	×	×	×	×	×	18
Greer et al. [23]	×	×	×	×	×	×	×	×	×	×	×	×	×	×		×	×	×	×	×	×	20
Laursen et al. [24]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Lizama et al. [25]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Lockhart et al. [26]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Lucena and Lesage [27]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Malik et al. [28]	×	×	×	×	×		×			×	×	×		×		×	×	×	×	×		16
Marshall and Phillips [29]	×	×	×	×	×		×	×		×		×	×	×	×	×	×	×			×	16
McConnell et al. [30]	×	×	×	×	×		×			×	×	×	×	×		×		×			×	14
Mitchell et al. [31]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Moritz et al. [32]	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	21
Otte et al. [33]	×	×	×	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	19
Schulte et al. [34]	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×		20
Shen et al. [35]	×	×	×	×	×		×	×		×		×	×	×		×	×	×	×	×	×	17
Lipitz‐ Snyderman et. [36]	×	×	×	×	×		×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	20
Tzartzas et al. [37]	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	21
Vrijmoeth et al. [38]	×	×	×	×	×		×	×	×	×	×	×	×	×		×	×	×	×	×	×	19
Wallace et al. [39]	×	×	×	×	×		×	×	×	×		×	×	×		×	×	×		×	×	17
Wilson et al. [40]	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	21
Wilson et al. [41]	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	×	21

3.3. Description of the Included Studies

The publication dates of the 22 selected studies were between 1999 and 2024. According to these studies, 9 articles were from North American countries (Canada and the United States) [21, 22, 23, 26, 27, 32, 36, 40], 7 articles were from European countries (the Netherlands, Switzerland, Germany, UK, and Denmark) [20, 24, 29, 33, 34, 37, 38], 5 articles were from Australia [25, 30, 31, 39, 41], and it is noticeable that only 1 article was from Asia (Pakistan) [28] and there was no article from Africa. The overall sample size of these studies was 484 GPs, 17 articles used semi‐structured interviews for data collection, and 5 studies used only focus group discussion [23, 36, 37, 41], or a self‐report survey [25]. Finally, all included articles used qualitative methods. A summary of the characteristics of the selected articles is presented in Table 2.

Table 2.

Summary characteristics of the studies (theme reported: I = Structural barriers, II = Regulatory and procedural barriers, III = Technological barriers to communication, IV = Personal and interpersonal barriers to communication.

Author/year	Country	Aim	Population	Sampling method	Data collection	Data analysis	Theme
Berendsen et al. [20]	Netherlands	What motivates GPs to initiate and sustain new models for collaborating with medical specialists?	21 General Pediatricians	Purposive sampling/maximum variation	Semi‐structured interview	Thematic analysis	II, IV
Easley et al. [22]	Canada	To explore health care provider (HCP) perspectives on the coordination of cancer care between FPs and cancer specialists.	21 Family Physicians	Purposive sampling/maximum variation	Semi‐structured interview	Not exist	II, III, IV
Greer et al. [23]	The United States	To identify PCPs' perceptions of key barriers and facilitators to effective comanagement of patients with CKD at the PCP‐nephrology interface.	32 Primary Care Physicians	Purposive sampling/maximum variation	Focused group discussions	Content analysis	I, II, IV
Laursen et al. [24]	Denmark	To explore whether general practitioners experienced barriers toward medication reviews in polymedicated, multimorbid patients.	14 General Pediatricians	Purposive sampling	Semi‐structured interview	Content analysis	I, II, IV
Lizama et al. [25]	Australia	To investigate general practitioners' (GP) perceptions about communication when providing cancer care.	68 General Pediatricians	Random sampling	Self‐report survey	Content analysis	II, IV
Lockhart et al. [26]	Canada	To explore the dynamics of primary care physicians' (PCPs') engagement with the Seamless Care Optimizing the Patient Experience (SCOPE) project.	22 Primary Care Physicians	Purposive sampling/criterion sampling	Semi‐structured interview	Grounded theory–informed analytic approach	I, II, IV
Lucena and Lesage [27]	Canada	To understand how to improve collaboration between psychiatrists and family physicians in primary care settings.	5 Family Physicians	Convenience sampling	In‐depth interviews and focus group discussions	Content analysis	I, II
Malik et al. [28]	Pakistan	To what degree are physicians satisfied with their current access to advice from human sources on difficult‐to‐diagnose cases?	11 Primary Care Physicians	Purposive sampling/criterion sampling	In‐depth interviews	Content analysis	I, IV
Marshall and Phillips [29]	The United Kingdom	To determine the state of the professional relationship between family physicians and hospital specialists.	12 General Pediatricians	Purposive sampling	In‐depth interviews and focus group discussions	Content analysis	II, IV
McConnell et al. [30]	Australia	To determine the purpose/function and preferred content of referral and reply letters as perceived by oncologists and referring doctors, respectively.	11 General Pediatricians	Not exist	Semi‐structured interview	Content analysis	II, III
Mitchell et al. [31]	Australia	To explore General Practitioners' perceptions of their role in cancer care and factors which influence this role.	12 General Pediatricians	Snowball sampling	Interviews and focus group discussions	Thematic analysis	I, II, III
Moritz et al. [32]	Canada	To explore family physicians' perspectives on specialist care availability during the pandemic and implications for family physician workload and patient management.	68 Family Physicians	Snowball sampling	Semi‐structured interview	Thematic and framework analyses	I, II, IV
Otte et al. [33]	Switzerland	To identify possible difficulties and barriers to effective collaboration at the EOL between GPs and HPs from the perspective of Swiss GPs.	23 General Pediatricians	Purposive sampling	Semi‐structured interview	Content analysis	II, III
Schulte et al. [34]	Germany	To detect and better understand the factors that influence whether referrals from GPs are made, and at what stage, to specialized pain centers.	10 General Pediatricians	Purposive sampling/maximum variation	Semi‐structured interview	Content analysis	I, II
Shen et al. [35]	The United States	To understand primary care providers' (PCPs') perceptions of communication with oncologist.	10 Primary Care Physicians	Purposive sampling/criterion sampling	Semi‐structured interview	Inductive thematic text analysis.	II, IV
Lipitz‐Snyderman et al. [36]	The United States	To elicit physicians' perceptions about and experiences with communication among physicians regarding diagnostic delays in cancer.	41 Physicians	Purposive sampling/criterion sampling	Focused group discussions	Content analysis	I, II, III, IV
Stille et al. [21]	The United States	To describe barriers and facilitators to effective generalist‐subspecialist communication in the care of children with chronic conditions.	14 General Pediatricians	Purposive sampling/maximum variation	Focused group discussions and individual interviews	Content analysis	II, III
Tzartzas et al. [37]	Switzerland	To investigate the experience of consultation‐liaison psychiatry interventions in primary care settings.	10 primary care physicians	Purposive sampling/criterion sampling	Focused group discussions	Thematic deductive and inductive analysis	IV
Vrijmoeth et al. [38]	Netherlands	To unravel the nature of the current primary care physician (PCP)‐(elderly care physicians) ECP collaboration in primary care for frail older persons.	7 Primary Care Physicians	Purposive sampling/maximum variation	Semi‐structured interview	Thematic analysis	II, IV
Wallace et al. [39]	Australia	To identify the challenges GPs face in effectively responding to CHB. To identify the challenges GPs face in effectively responding to CHB.	26 General Pediatricians	Purposive sampling/maximum variation	Semi‐structured interview	Not exist	II, IV
Wilson et al. [40]	Canada	To explore rural physicians' perspectives on communication with urban specialists during consultations and referrals.	11 Primary Care Physicians	Purposive sampling/maximum variation	Semi‐structured interview	Thematic analysis	I, II, IV
Wilson et al. [41]	Australia	To explore how specialist AOD services could better support GPs to address their patients' AOD issues.	35 General Pediatricians	Purposive sampling/maximum variation	Focused group discussions	Thematic analysis	II, III, IV

3.4. Thematic Analysis Results Regarding the Barriers to Communication

3.4.1. The First Theme: Structural Barriers to Communication

At the macro level, for any health system to support effective communication and collaboration, some groundwork needs to be prepared. There are many types of structural prerequisites that could affect the quality of communication between GPs and specialists. However, we distinguished two main subthemes in this study.

3.4.1.1. Low Policy Priority

The first important barrier that GPs mentioned is that health policymakers and other authorities do not prioritize primary healthcare in the health system:

I think that it just has to do with the institutions becoming bigger and focusing more on priority programs, which are often not primary care‐based programs …. These programs usually leave primary caregivers out of the equation.

[26]

Second, from the perspective of GPs, the lack of a functional referral system is one of the barriers. In fact, creating a referral health system should be integrated into a well‐operating health system to be effective, and if there is no efficient healthcare system in a country, this indirectly leads to poor communication between GPs and specialists:

No one wants to work in a system that doesn't work. It leads to frustration, going through four hands, being transferred around [public] hospitals and trying to follow up.

[31]

Moreover, unsuitable accessibility to the health system is another important factor to be considered. Because it affects the collaboration between service providers:

You know we're all in this crappy system together, and I can't accept your patient sorry, but this is what you should do. We're in a crappy broken system that's too expensive.

[40]

The fourth factor is an ineffective organizational culture. In the referral system, there are notable cultural and organizational differences between the primary, secondary, and tertiary healthcare sectors. These differences often result in the absence of an open and trusted communication culture, which is essential for effective collaboration. For instance, in the primary care sector, general practitioners (GPs) may prioritize patient‐centered approaches, while specialists in secondary and tertiary care may emphasize technical expertise and procedural efficiency. Such contrasting priorities can create barriers to communication, leading to misaligned goals and reduced trust between GPs and specialists. Addressing these cultural and organizational disparities is critical to fostering a communication environment that enables seamless collaboration across all levels of care:

You need to be able to join forces more freely, getting hold of the different stakeholders that are involved with the patient. I often experience that it can be difficult.

[24]

3.4.1.2. Shortages in the Number of Specialists and Heavy Workload

Another important health structural barrier that affects collaboration is shortages of specialists in the referral system. This barrier leads to less accessibility to health services:

…you're going to have some access issues,…because they [insurance carriers] just haven't contracted with enough nephrologists or the nephrologists are not geographically in a convenient place for that patient…Many PCPs also noted their frustration with being unable to easily contact nephrologists with issues or concerns regarding patients' CKD care, which may contribute to significant delays in patient care.

[23]

However, this also results in a heavy workload and less communication between specialists and GPs:

Normally we would have an infectious disease specialist as well, but he … was very busy.

[32]

I am in my office here, inundated with 70 patients a day and I see my patients here and that is it. I stopped—I don't have hospital privileges anymore … I don't have that liaison with other physicians, it's just me. I am here alone.

[26]

3.4.2. The Second Theme: Regulatory and Procedural Barriers to Communication

This obstacle prevents effective communication and collaboration between GPs and specialists and arises from policies, laws, regulations, and defined procedures. Six subthemes for this barrier emerged in this study:

3.4.2.1. Lack of Comprehensive Communication Protocols

A lack of an established protocol that sets clear communication guidelines can lead to misunderstanding, confusion, and inefficiency in the collaboration between GPs and specialists:

GPs are often stuck for advice…. Having established routes of contact and how they can easily and quickly get hold of people to ask their questions is the most important thing.

[39]

Moreover, the lack of a formalized process agreement between different sectors in the health system can affect the quality of collaboration:

Did we formalize that? No, actually not. No, that just grew over the course of the time.

[38]

The specialist dictates how it should be done and we simply nod in acquiescence.

[20]

3.4.2.2. Unclear Delineation of Roles and Responsibilities

This barrier occurs when expectations from GPs and specialists and their roles regarding communication in any referral system in a special situation are not defined. In the health system, this is a major problem that can present many challenges for the health system, health service providers, and patients:

The primary care physician has not been part of the decision‐making process”; “My patient who sees two different subspecialists is hard to coordinate because each one wants to manage differently.

[21]

Another important problem would be ethical and legal perspectives:

Moreover, from an ethical and also legal perspective, such involvement of GPs in EOL decision making may give rise to the question of whether GPs could be designated as informal substitute decision makers or take on more formal decision‐making roles.

[33]

3.4.2.3. Inadequate Economic Incentives

The lack of a well‐defined structure and model for communication reimbursement is a key barrier to communication between GPs and specialists in any referral system. This limitation makes spending time on collaboration and communication impractical:

I do not have the energy to tour medical clinics. I think it would be a waste of time. … I am not even supposed to be paid if I am not on the premises of the hospital.

[27]

3.4.2.4. Lack of Continuity Between Providers

This problem leads to fragmentation and gaps in care coordination and information sharing in referral systems. One reason for this discontinuity is the change in the workplace of GPs and specialists:

If the patient's provider changes and nobody tells me, I'm wasting my time dictating letters.

[21]

3.4.2.5. Lack of Interest in Specialists and Secondary‐Level of Referral System to Communicate About Referred Patients

This is a significant barrier to effective care coordination that has been described in many articles because of poor communication and teamwork procedures between the primary and secondary levels:

And with the lack of timely communication from hospitals based services and the unfortunate tendency to leave the GP out of the “information loop”, the GP is not part of any “team” caring for patients.

[25]

Yeah, well, oftentimes you'll hear that initially…what's going on, what they've done, and then, you know, oftentimes, there's this great void of time, and you don't hear anything.

[35]

Furthermore, due to the lack of tendency among specialists to communicate;

…[W]hat the specialist has told the patient and that's a bit hard to see in a letter. That's really important because patients often obviously don't hear… but often they are not told where they are at and it's difficult to have a conversation with them.

[31]

3.4.2.6. Time‐Consuming Communication Process

This problem occurs when the message is not clear, and there are no key details about it. As a result, multiple back‐and‐forth communications can occur:

I'm sure I could write a decent referral, but it would take me a long time and I'd try to think about what you might want to know from me and my history taking. But to know exactly what you want or need on a referral to facilitate that connection would be helpful.

[41]

3.4.3. The Third Theme: Technological Barriers to Communication

Different technological limitations are very important contributing factors that can affect the quality of communication between GPs and specialists. With respect to this obstacle, two subthemes emerged:

3.4.3.1. Ineffective Method for Communication

Using any unsuitable technique, channel or approach for communication between GPs and specialists can lead to communication failure:

I wasted so much time leaving messages, waiting for a callback, trying to find the right number for somebody's office. And so unless it's really easy, I just assume that they get my letter and history and physical and get the information that way because it is far more challenging [to] actually [speak] with somebody than anticipated.

[36]

I spent three quarters of an hour chasing around to the [cancer specialist] at the [metropolitan public hospital], eventually got [the consultant] on the phone. She said ‘Send [the patient] in tomorrow’.

[31]

3.4.3.2. Challenges in Using Electronic Medical Records

Several challenges were identified in this study that can affect the quality of communication between GPs and specialists. For example, incompatibility of EMR software programs at different levels of the referral system is one of the most important issues:

Sometimes I find that there's a big delay in written documents being transferred …. There [are] the hospital‐based electronic files, and then there is the clinic‐based electronic medical record and they don't always talk to each other, or [it]seems like things are either delayed or lost in the shuffle. So there is a lot of tracking down on the part of me and my staff here to see the most up‐to‐date information. It can be very frustrating.

[22]

Furthermore, complex EMR systems [21], the problem of finding suitable physicians at the same or another institution [22, 36], and different EMR in one health system [36] are other mentioned challenges.

3.4.4. The Fourth Theme: Personal and Interpersonal Barriers to Communication

Some personal and interpersonal factors can negatively affect the quality of communication. From the perspective of GPs, there are five main factors:

3.4.4.1. Having Different Approaches to Healthcare

From the perspective of GPs, their preferences are long‐term and patient‐centered care. In contrast, specialists are technically disease‐oriented:

If the medicine has been changed at the hospital, without you knowing why, it creates uncertainty, because it may be medicine that I think is necessary for the patient. Some specialists at the hospital only focus on one illness, regardless of how it will transmit when the patient gets home.

[24]

3.4.4.2. Inappropriate Specialists' Perceptions of Family Physicians' Roles

A lack of understanding of GPs' working conditions by specialists and a lack of knowledge about GPs' activities can lead to an inappropriate perception of specialist on GPs roles, and it affects the quality of collaboration:

Some (consultants) don't understand the environment that we're in here…so I've had experiences like calling a cardiologist from a [remote] community and them saying like well why is that patient there and I'm saying well because they live here, and them saying well why can't you send them on a medevac to us tonight, and [me saying] because the runway doesn't have lights and we can't fly at night and just having this nonsense back and forth.

[40]

3.4.4.3. Lack of Professional Trust and Respect

A lack of trust and respectful working conditions in the referral system can directly affect collaboration between GPs and specialists:

From a family doctor's side of things…we're the patient's advocate. So if we're calling (a specialist) it's for [the patient] and it's kind of our job to get the most out of this conversation as possible. So sometimes that means some moments of discomfort and feeling like you're asking too many questions or being too persistent.

[40]

3.4.4.4. Lack of Professional Interpersonal Networks

When GPs and specialists do not know each other, it leads to significant negative impacts on their teamwork, and it may result in poor collaboration, decreasing trust, and communication breakdown in the referral system:

I contact my colleagues and friends even outside the district because every specialist within the district cannot be contacted in personal relationships. For example, it is not possible to contact Dr. Z because he is not known to me.

[28]

3.4.4.5. Social Anxiety Disorder in the Workplace

From the perspective of GPs, fear of being judged by both GPs and specialists affects communication between them:

Because most of us feel terrible already when our patients have cancer, to have an oncologist call you and say, ‘You're an idiot, how'd you miss this?’ would be pretty devastating.

[36]

Table 3 indicates themes, subthemes, and codes of selected studies.

Table 3.

Themes, subthemes, and codes of selected studies.

Themes	Subthemes	Example of codes	Sub‐themes references
Structural barriers	Inefficient health system	− Unsuitable referral system. − Not giving priority to primary healthcare.	[1, 2, 3, 4, 5, 6]
	Shortages in the number of specialists and heavy workload	− Limited Access to specialists. − Heavy workload of specialists.	[1, 7, 8, 9, 10]
Regulatory and procedural barriers	Lack of a comprehensive communication protocol	− Lack of suitable guideline for communication. − Lack of process agreements.	[5, 8, 11, 12, 13, 14, 15]
	Unclear delineation of roles and responsibilities	− Failure to discuss division of responsibility. − Lack of clarification of roles and expectations.	[5, 7, 11, 12, 13, 14, 15, 16, 17]
	Inadequate economic incentives	− Lack of support with reimbursement. − Telephone consultation is not included in the billing fee.	[3, 9, 10]
	Lack of interest in specialists and the secondary level of referral system to communicate about referred patients	− Lack of sufficient feedback from specialists. − Slow procedures in the secondary level for sending feedback.	[1, 2, 4, 7, 8, 9, 11, 16, 17, 18, 19, 20, 21]
	Time‐consuming communication process	− Unnecessary information in the referral letter. − Writing detailed letters is time‐consuming.	[19, 20]
Technological barriers to communication	Ineffective method for communication	− Technological prerequisites. − Lack of a suitable pathway for communication.	[2, 5, 11, 19]
	Challenges in using electronic health records	− Difficulties in contacting the appropriate provider. − Incompatibility of the electronic medical record software program.	[5, 12, 17, 20]
Personal and interpersonal barriers to communication	Having different approaches to healthcare	− Specialists only focus on one illness aspect. − Different approach of FPs and Specialist.	[4, 16]
	Inappropriate specialists' perception on family physicians' roles	− Lack of knowledge in specialist about geographical isolation. − Underestimating the role of FPs by specialists.	[3, 8, 15, 18, 21]
	Lack of professional trust and respect	− Negative or defensive reaction by the specialists. − Lack of enough respect from specialists.	[5, 6, 7, 13, 14, 15, 18, 20]
	Lack of a professional interpersonal network	− Poor working relationships with specialists. − Lack of teamwork.	[4, 6, 7, 14, 17, 22]
	Social anxiety disorder at the workplace	− Fears about disclosing errors to patients. − Concern about assigning blame to them.	[1, 5]

4. Discussion

The shift toward managing non‐communicable diseases (NCDs) post‐COVID‐19 underscores the urgency of strengthening referral systems [42], particularly in low‐ and middle‐income countries (LMICs) where communication gaps between GPs and specialists persist. While countries like Germany and Switzerland exemplify successful referral models, LMICs often lack the infrastructure and policies to support effective collaboration [43]. From the perspective of GPs, we identified four major barriers: structural barriers, regulatory and procedural, technological barriers, and personal and interpersonal barriers.

Structural inefficiencies, such as fragmented health systems and specialist shortages, exacerbate workloads and limit access to specialized care. These challenges are compounded by regulatory ambiguities, including poorly defined communication protocols and inadequate financial incentives for interdisciplinary collaboration. For instance, the absence of standardized referral pathways often results in duplicated efforts and delayed diagnoses [44], as evidenced by GP reports of “time‐consuming communication processes” and “unclear roles” [41].

Addressing these issues requires policy reforms that prioritize primary care integration [45], redistribute specialist workloads, and establish reimbursement models for interdisciplinary consultations [32]. Moreover, building a shared responsibility for patient care [20], defining financial incentives for consolation [44], establishing nonpunitive and non‐judgmental feedback [46], and defining the timeliness of communication in both directions based on disease severity [35] are vitally important solutions for improving collaboration.

Technological limitations, such as incompatible electronic medical records (EMRs), further hinder information sharing. While telemedicine and interoperable digital platforms offer solutions [47], their implementation must align with local health system capacities to avoid exacerbating disparities [48]. For example, GPs highlighted frustrations with “tracking down delayed or lost records” due to incompatible EMRs, underscoring the need for context‐specific technological investments.

Interpersonal dynamics, including role misperceptions and lack of trust, reflect deeper systemic inequities between primary and specialty care. Specialists' disease‐centric approaches often clash with GPs' patient‐centered priorities, fostering misunderstandings. Interventions such as interprofessional education and structured clinical forums could bridge these divides by fostering mutual respect and clarifying roles [49]. As one GP noted, collaborative environments reduce “moments of discomfort” when advocating for patients [50]. Moreover, some studies suggest that purposeful meetings between GPs and specialists to discuss different clinical situations are important facilitators for improving communication and collaboration between them [51]. Figure 2 illustrates communication barriers and the best solution for them.

Figure 2.

Communication barriers and the best solution for them.

4.1. Limitations

Like other studies with meta‐synthesis methods, one challenge is limited access to qualitative studies related to the selected topic. To address this limitation, we tried to use suitable available electronic resources to find the maximum number of eligible articles to include in this study. Another important limitation was limited access to qualitative studies about the communication barriers between GPs and specialists in developing countries. Because referral systems in PHC in different countries are at various levels of implementation, some suggestions may not be practical for some countries.

5. Conclusions

Health policymakers must prioritize structural and procedural reforms, including standardized communication frameworks, interoperable digital infrastructure, and interprofessional training programs. Addressing these gaps can enhance referral system efficiency, reduce diagnostic delays, and strengthen health system resilience, particularly in low‐resource settings.

Author Contributions

Hamed Fattahi: formal analysis, writing – original draft, writing – review and editing, methodology, data curation, software, and conceptualization. Faezeh Ghasemi Seproo: methodology, writing – review and editing, formal analysis, data curation, software, and visualization. Arash Fattahi: writing – review and editing, formal analysis, writing – original draft, supervision, project administration, and validation. Vahideh Rostami: methodology and writing – original draft. Azad Shokri: writing – review and editing, funding acquisition, data curation, investigation, and resources. All authors have read and approved the final version of the manuscript. Arash Fattahi had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

Ethics Statement

All procedures performed in studies involving human participants were approved by the Ethics Committee of the Kurdistan University of Medical Sciences under ethics code no. IR.MUK.REC.1403.170.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author Arash Fattahi affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Supporting information

supporting file 1.

Data Availability Statement

The data sets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.