I remember being a junior doctor and always putting off making specialty referrals to the end of the day. For some reason, I didn’t like getting grilled or even flat out told off for making a rubbish referral. Now, having made it to the other end of the phone, I try to be humane in how I deal with every dermatology referral.
Before we get into the specifics of the best way to make a dermatology referral, remember that the person on the other end is a human. They might be stressed, a general grump or you might have caught them in the middle of an overrunning clinic. Please don’t misconstrue this: this isn’t an excuse for bad behaviour by the dermatologist. Rather, it’s an explanation for why, despite making an excellent referral, they might still give you a hard time.
Step 1 – Get to know the referral guidelines in your hospital
Some hospitals only operate a phone on-call service for urgent referrals (read: A&E) and request an electronic dermatology referral for everything else. Before picking up the phone, ensure you’re referring via the correct pathway. If you can’t find any information (or you have serious clinical concerns), always pick up the phone. If it’s a dodgy widespread rash, it will likely need a ward visit by the dermatologist. If you’re worried about a dodgy lesion that you think might be cancer, it’s likely better managed by making a Two Week Rule referral.
Step 2 – look at the clock
Dermatologists spend most of the day within clinic and so reviewing ward patients can be tricky. That being said, we recognise that it’s part of the job. If you know you need to make a referral to dermatology, try and do it as soon as you can – this makes it more likely that your patient gets reviewed on the same day. Leaving it until 4.50pm is going to irritate even the most placid of dermatologists. If it’s after 5pm and the referral isn’t urgent, leave it until the next day. Dermatology registrars provide a regional on-call service (i.e. the person you’re referring to may not be based at the hospital you’re at). If the review can’t wait until the next day, it’s perfectly fine to refer out-of-hours.
Step 3 – have all the information to hand
This sounds obvious but I can remember the chaos that goes on within a busy ward. Someone might have nicked the drug chart, someone else has the paper notes, someone else is logged in and has locked the electronic record. Before picking up the phone, ensure you have everything you need to hand. If you’re dealing with a widespread rash that could be drug-related, have a timeline of medications ready – we will ask for it and it will probably nail the diagnosis!
Step 4 – lead with your headline
- Introduce yourself – I’m Sarah, an FY1 on Derby Ward. (You can mention the named consultant who’s asked for a review for added oomph.)
- I’d like to refer a patient for remote discussion/an in-person review
- How urgently you need it with justification – in the next 24 hours/within the next few days as we can discharge her once the patient is reviewed
- Clinical photographs if you have them – dermatologists are very visual – we can often make the diagnosis from a picture. If you’re going to share them, make sure you do it securely. WhatsApp might be fine for gossip but it may land you in hot water if used to share clinical photographs. NHSMail is a safe bet.
Step 5 – clinical information
- Demographics: age/sex of patient
- A BRIEF progress history and duration (e.g Mrs. Thompson was admitted on Tuesday with this rash that has been worsening over the last few days.)
- Previous treatments trialled
- Physical examination findings (e.g. this lady has a widespread urticarial eruption)
- Investigations (e.g. this lady has a mild eosinophilia – a raised eosinophil count can be seen in eczema, allergy as well as bullous pemphigoid)
- If appropriate, mention the presence or absence of red flags (e.g. skin tenderness, mucosal involvement, blistering)
Step 6 – Document the treatment plan
Prior to physical review, most dermatologists will recommend some initial management – this might include emollients/topical steroids and sometimes antihistamines. Ask for the name of the doctor who’s given the advice before putting down the phone.
Step 7 – Liaise with pharmacy and nursing colleagues
Get me the Diprobase, STAT! – screamed the Emergency Medicine Registrar, never
Dermatology plans are rarely considered a high priority within the hospital. One of our biggest irritations is where we make treatment recommendations, come back for a routine review on the ward and find that nothing has been actioned. If it’s an urgent issue (e.g. suspected severe drug eruption), page the on-call pharmacist. Ensure that you’ve obtained adequate quantities of the creams. Case-in-point, if someone needs their whole body covered in Betnovate, you will need to request 2 x 100g tubes to ensure adequate coverage for a few days. If you don’t specify this, the pharmacy may give the nurses a measly 30g tube that won’t do for one visit.
Step 8 – sit back in restful bliss
Eat a Kit Kat, gloat, put your feet up. Or, more realistically scoot onto the next job on your interminable jobs list!