The challenging task of gatekeeping

In this issue of MFP, Ang AT et al looks at the important role of a Family Physician as a gatekeeper.1 The study was conducted in 28 public primary care clinics across four states in Malaysia. They found that out of 100 clinical encounters, there was an average of about 2 referrals (1.76%). It is reassuring to know that most of the referrals were appropriate. The authors have also identified several predictors of referral: complexity of the disease, prior consultations with senior doctors, and availability of the facilities to confirm a diagnosis. However, it is important to note that the study excluded referrals for neonates and from maternal child health clinic. In addition, the appropriateness of the referrals was assessed by Family Medicine Specialists who might have assessment bias.

In general practice, patients often present at an early stage of the illness, which makes diagnosis and treatment challenging. Family Physicians, therefore, run the risk of missing a serious condition or not picking it up early enough for intervention. On the other hand, some of the referrals from primary care to the hospitals are considered by specialists to be unnecessary as it is easier to make a diagnosis in hindsight. This is the challenge of working as a Family Physician in the primary care. Factors such as doctors’ training and experience, support from hospital colleagues and availability of laboratory services influence doctors’ decision and threshold to refer.

A good example is how difficult it can be for the Family Physician to decide whether or not to refer a patient with suspected dengue fever to the hospital. Despite clear guidelines,2 the management of dengue infection remains challenging due its variable clinical presentations and unpredictable course of illness. Should the doctor refer a patient who looks dehydrated and tired but whose blood investigations are only mildly deranged? Or should the doctor monitor the patient closely in his clinic and run the risk of the patient deteriorating? The decision becomes even more difficult when the patient is not keen to repeat the blood test or return for follow up. As much as the Family Physician want to be a good gatekeeper, the fear of missing a serious diagnosis and its repercussion is a real one.

Recently, the Family Medicine Specialist Association and the Academy of Family Physicians of Malaysia, together with the Ministry of Health, published the ‘Primary Care Referral Guidelines’, which contains practical information on what, how, when, where and who to refer.3 It can serve as a practical guide for busy Family Physicians who need to make a quick decision about referral. The next step is to put in place a system to provide training for doctors to fill the gaps in their clinical knowledge and skills, to improve the communication between primary and secondary care, and to allow doctors to communicate effectively to patients and their family about the uncertainty of the diagnosis and treatment, and your decision to refer (or not to refer).