Barrett and Landon suggest two main reasons for the increase. First, care in certain arenas is more complex, demanding more training and experience that only specialists have. For example, Landon points to cardiology or ear, nose and throat symptoms, "where over time there has been the introduction of more treatments, more technology, and more innovation."
The number of visits resulting in a referral to a cardiologist increased from 8.5% to 14.9% and the number resulting in a recommendation to an ENT went from 4.5% to 8.5%. Orthopedic referrals went from 12.4% to 16.5% and those for dermatology consults went from 10.1% to 15.4%.
But the second reason has to do with what Landon calls "the tyranny of the 15-minute visit." Today, a physician has more guidelines to follow, his or her patients are older and sicker with more co-morbid conditions. "There's only so much a primary care physicians can do in the small time allotted, so they say, 'I'll address problems A and B, but problem C, I'll give that to a specialist.' "Of course, the time the doctor allots is influenced, at least in part, by how much the payer reimburses."
The Harvard study got an edgy reaction in an editorial by Mitchell Katz, MD, who directs health services for the County of Los Angeles and is a practicing internist. Katz’s commentary was headlined, "How Can We Know So Little About Physician Referrals?"
Katz says it's unclear "whether we are currently referring too often, too infrequently or (most likely) both, depending on the patient and the situation." Are patients demanding referrals more "or are we referring more because of concerns of malpractice?" which of course brings up a third reason for referrals.