{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T15:38:06Z","timestamp":1784907486533,"version":"3.55.0"},"reference-count":36,"publisher":"Oxford University Press (OUP)","issue":"1191","license":[{"start":{"date-parts":[[2024,8,29]],"date-time":"2024-08-29T00:00:00Z","timestamp":1724889600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/academic.oup.com\/pages\/standard-publication-reuse-rights"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":[],"published-print":{"date-parts":[[2024,12,23]]},"abstract":"<jats:title>Abstract<\/jats:title>\n               <jats:p>Subspecialty consultations are becoming highly prevalent in hospital medicine, due to an ageing population with multimorbid conditions and increasingly complex care needs, as well as medicolegal fears that lead to widespread defensive medical practices. Although timely subspecialty consultations in the appropriate clinical context have been found to improve clinical outcomes, there remains a significant proportion of specialty referrals in hospital medicine which are inappropriate, excessive, or do not add value to patient care. In this article, we sought to provide an overview of the common problems pertaining to excessive quantity and suboptimal quality of inpatient subspecialty consultations made in real-world practice and highlight their implications for healthcare financing and patient care. In addition, we discuss the underlying contributing factors that predispose to inappropriate use of the specialist referral system. Finally, we offer a practical, multitiered approach to help rationalize subspecialty consultations, through (i) a systematic model (\u2018WISE\u2019 template) for individual referral-making, (ii) development of standardized healthcare institutional referral guidelines with routine clinical audits for quality control, (iii) adopting an integrated generalist care model, and (iv) incorporating training on effective referral-making in medical education.<\/jats:p>","DOI":"10.1093\/postmj\/qgae106","type":"journal-article","created":{"date-parts":[[2024,8,28]],"date-time":"2024-08-28T20:41:58Z","timestamp":1724877718000},"page":"76-83","source":"Crossref","is-referenced-by-count":6,"title":["Referring wisely: knowing when and how to make subspecialty consultations in hospital medicine"],"prefix":"10.1093","volume":"101","author":[{"given":"Isaac K S","family":"Ng","sequence":"first","affiliation":[{"name":"Internal Medicine Residency Program , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"National University Hospital , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Shir Lynn","family":"Lim","sequence":"additional","affiliation":[{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]},{"name":"Department of Cardiology, National University Heart Center , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"Pre-hospital Emergency Research Center, Duke-NUS Medical School , 8 College Road, Singapore 169857,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Kevin S H","family":"Teo","sequence":"additional","affiliation":[{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]},{"name":"Division of Neurology , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"National University Hospital , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Wilson G W","family":"Goh","sequence":"additional","affiliation":[{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]},{"name":"Division of Infectious Diseases , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"National University Hospital , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christopher","family":"Thong","sequence":"additional","affiliation":[{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]},{"name":"Division of Respiratory and Critical Care Medicine , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]},{"name":"National University Hospital , Department of Medicine, , 5 Lower Kent Ridge Road, Singapore 119074,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Joanne","family":"Lee","sequence":"additional","affiliation":[{"name":"Yong Loo Lin School of Medicine, National University of Singapore , 10 Medical Dr, Singapore 117597,","place":["Singapore"]},{"name":"Department of Haematology-Oncology, National University Cancer Institute , National University Health System, 1E Kent Ridge Road, NUHS Tower Block, Level 7, Singapore 119228,","place":["Singapore"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"286","published-online":{"date-parts":[[2024,8,29]]},"reference":[{"key":"2024122317355941500_ref1","doi-asserted-by":"crossref","first-page":"73","DOI":"10.1016\/j.rdc.2019.09.003","article-title":"Enhancing the inpatient consultation learning environment to optimize teaching and learning","volume":"46","author":"Serling-Boyd","year":"2020","journal-title":"Rheum Dis Clin N Am"},{"key":"2024122317355941500_ref2","doi-asserted-by":"crossref","first-page":"992","DOI":"10.1007\/s11606-015-3216-7","article-title":"Variation in inpatient consultation among older adults in the United States","volume":"30","author":"Stevens","year":"2015","journal-title":"J Gen Intern Med"},{"key":"2024122317355941500_ref3","doi-asserted-by":"crossref","first-page":"129","DOI":"10.1186\/s12875-015-0344-4","article-title":"Challenges of managing people with multimorbidity in today\u2019s healthcare systems","volume":"16","author":"Moffat","year":"2015","journal-title":"BMC Fam Pract"},{"key":"2024122317355941500_ref4","doi-asserted-by":"crossref","first-page":"2609","DOI":"10.1001\/jama.293.21.2609","article-title":"Defensive medicine among high-risk specialist physicians in a volatile malpractice environment","volume":"293","author":"Studdert","year":"2005","journal-title":"JAMA"},{"key":"2024122317355941500_ref5","doi-asserted-by":"crossref","first-page":"e1921048","DOI":"10.1001\/jamanetworkopen.2019.21048","article-title":"Association of infectious diseases consultation with long-term postdischarge outcomes among patients with Staphylococcus aureus bacteremia","volume":"3","author":"Goto","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2024122317355941500_ref6","doi-asserted-by":"crossref","first-page":"e00199","DOI":"10.1002\/edm2.199","article-title":"The impact of diabetology consultations on length of stay in hospitalized patients with diabetes","volume":"4","author":"Sheahan","year":"2021","journal-title":"Endocrinol Diabetes Metab"},{"key":"2024122317355941500_ref7","doi-asserted-by":"crossref","first-page":"733","DOI":"10.1056\/NEJMoa1000678","article-title":"Early palliative care for patients with metastatic non-small-cell lung cancer","volume":"363","author":"Temel","year":"2010","journal-title":"N Engl J Med"},{"key":"2024122317355941500_ref8","doi-asserted-by":"crossref","first-page":"1328","DOI":"10.1245\/s10434-023-14528-7","article-title":"Association of inpatient palliative care consultation with clinical and financial outcomes for pancreatic cancer","volume":"31","author":"Kim","year":"2024","journal-title":"Ann Surg Oncol"},{"key":"2024122317355941500_ref9","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2019.21750","article-title":"Association of variation in consultant use among hospitalist physicians with outcomes among Medicare beneficiaries","volume":"3","author":"Stevens","year":"2020","journal-title":"JAMA Netw Open"},{"key":"2024122317355941500_ref10","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2019.1634","article-title":"Association of Medicare spending with subspecialty consultation for elderly hospitalized adults","volume":"2","author":"Ryskina","year":"2019","journal-title":"JAMA Netw Open"},{"key":"2024122317355941500_ref11","doi-asserted-by":"crossref","first-page":"511","DOI":"10.1136\/postgradmedj-2020-137624","article-title":"Completeness and quality of text paging for subspecialty consult requests","volume":"97","author":"Chu","year":"2021","journal-title":"Postgrad Med J"},{"key":"2024122317355941500_ref12","doi-asserted-by":"crossref","first-page":"e228867","DOI":"10.1001\/jamanetworkopen.2022.8867","article-title":"Patient and clinician perceptions of factors relevant to ideal specialty consultations","volume":"5","author":"Roche","year":"2022","journal-title":"JAMA Netw Open"},{"key":"2024122317355941500_ref13","doi-asserted-by":"crossref","first-page":"59","DOI":"10.1136\/qshc.2007.025486","article-title":"Audit of the consultation process on general internal medicine services","volume":"18","author":"Conley","year":"2009","journal-title":"Qual Saf Health Care"},{"key":"2024122317355941500_ref14","doi-asserted-by":"crossref","first-page":"220","DOI":"10.1513\/AnnalsATS.201212-120OC","article-title":"Elements of a high-quality inpatient consultation in the intensive care unit: a qualitative study","volume":"10","author":"Stevens","year":"2013","journal-title":"Ann Am Thorac Soc"},{"key":"2024122317355941500_ref15","doi-asserted-by":"crossref","first-page":"95","DOI":"10.1007\/BF02600506","article-title":"Diagnostic test restraint and the specialty consultation","volume":"5","author":"Braham","year":"1990","journal-title":"J Gen Intern Med"},{"key":"2024122317355941500_ref16","doi-asserted-by":"crossref","first-page":"106","DOI":"10.1016\/0002-9343(83)91126-9","article-title":"Impact of inter-physician communication on the effectiveness of medical consultations","volume":"74","author":"Lee","year":"1983","journal-title":"Am J Med"},{"key":"2024122317355941500_ref17","first-page":"57","article-title":"Neurology referral patterns","volume":"4","author":"Menken","year":"1990","journal-title":"HMO Pract"},{"key":"2024122317355941500_ref18","doi-asserted-by":"crossref","first-page":"149","DOI":"10.47102\/annals-acadmedsg.2022434","article-title":"Re-examining the roles of generalists and specialists in healthcare","volume":"52","author":"Khatri","year":"2023","journal-title":"Ann Acad Med Singap"},{"key":"2024122317355941500_ref19","doi-asserted-by":"crossref","first-page":"786","DOI":"10.1001\/jamainternmed.2014.300","article-title":"Effect of hospitalist workload on the quality and efficiency of care","volume":"174","author":"Elliott","year":"2014","journal-title":"JAMA Intern Med"},{"key":"2024122317355941500_ref20","doi-asserted-by":"crossref","DOI":"10.1001\/jamanetworkopen.2023.2648","article-title":"Factors associated with inpatient subspecialty consultation patterns among pediatric hospitalists","volume":"6","author":"Kern-Goldberger","year":"2023","journal-title":"JAMA Netw Open"},{"key":"2024122317355941500_ref21","doi-asserted-by":"crossref","first-page":"1814","DOI":"10.1097\/ACM.0000000000002337","article-title":"The Consultation Observed Simulated Clinical Experience: training, assessment, and feedback for incoming interns on requesting consultations","volume":"93","author":"Martin","year":"2018","journal-title":"Acad Med"},{"key":"2024122317355941500_ref22","doi-asserted-by":"crossref","first-page":"968","DOI":"10.1111\/j.1553-2712.2012.01412.x","article-title":"A prospective, randomized, controlled study demonstrating a novel, effective model of transfer of care between physicians: the 5 Cs of consultation","volume":"19","author":"Kessler","year":"2012","journal-title":"Acad Emerg Med"},{"key":"2024122317355941500_ref23","doi-asserted-by":"crossref","first-page":"42","DOI":"10.2310\/8000.2012.120762","article-title":"Understanding communication between emergency and consulting physicians: a qualitative study that describes and defines the essential elements of the emergency department consultation-referral process for the junior learner","volume":"15","author":"Chan","year":"2013","journal-title":"Can J Emerg Med"},{"key":"2024122317355941500_ref24","doi-asserted-by":"crossref","first-page":"113","DOI":"10.4300\/JGME-D-14-00207.1","article-title":"The courteous consult: a CONSULT card and training to improve resident consults","volume":"7","author":"Podolsky","year":"2015","journal-title":"J Grad Med Educ"},{"key":"2024122317355941500_ref25","doi-asserted-by":"crossref","first-page":"1053","DOI":"10.1111\/imj.16358","article-title":"\u2018Person-centred care\u2019: an overhyped clich\u00e9 or a practicable health delivery model?","volume":"54","author":"Ng","year":"2024","journal-title":"Intern Med J"},{"key":"2024122317355941500_ref26","doi-asserted-by":"crossref","first-page":"295","DOI":"10.4103\/singaporemedj.SMJ-2023-166","article-title":"Goals-of-care discussion in older adults: a clinical and ethical approach","volume":"65","author":"Ng","year":"2024","journal-title":"Singapore Med J"},{"key":"2024122317355941500_ref27","doi-asserted-by":"crossref","first-page":"459","DOI":"10.1186\/s12909-020-02285-0","article-title":"Teaching clinical handover with ISBAR","volume":"20","author":"Burgess","year":"2020","journal-title":"BMC Med Educ"},{"key":"2024122317355941500_ref28","doi-asserted-by":"crossref","first-page":"619","DOI":"10.1136\/postgradmedj-2011-130719","article-title":"Telephone referrals by junior doctors: a randomised controlled trial assessing the impact of SBAR in a simulated setting","volume":"88","author":"Cunningham","year":"2012","journal-title":"Postgrad Med J"},{"key":"2024122317355941500_ref29","doi-asserted-by":"crossref","first-page":"137","DOI":"10.1136\/qshc.2007.025247","article-title":"The teaching of a structured tool improves the clarity and content of interprofessional clinical communication","volume":"18","author":"Marshall","year":"2009","journal-title":"Qual Saf Health Care"},{"key":"2024122317355941500_ref30","doi-asserted-by":"crossref","first-page":"447","DOI":"10.1016\/j.cmi.2019.08.007","article-title":"How to start an antimicrobial stewardship programme in a hospital","volume":"26","author":"Mendelson","year":"2020","journal-title":"Clin Microbiol Infect"},{"key":"2024122317355941500_ref31","doi-asserted-by":"crossref","first-page":"782","DOI":"10.1007\/s11606-020-06271-6","article-title":"Back to the hospital for chronic care: a hybrid generalist model","volume":"36","author":"Sumner","year":"2021","journal-title":"J Gen Intern Med"},{"key":"2024122317355941500_ref32","doi-asserted-by":"crossref","first-page":"533","DOI":"10.1186\/s12909-022-03592-4","article-title":"An educational intervention to facilitate appropriate subspecialty referrals: a study assessing resident communication skills","volume":"22","author":"Stave","year":"2022","journal-title":"BMC Med Educ"},{"key":"2024122317355941500_ref33","article-title":"Fellow as Clinical Teacher (FACT) curriculum: improving fellows\u2019 teaching skills during inpatient consultation","author":"Chen","year":"2018","journal-title":"MedEd PORTAL"},{"key":"2024122317355941500_ref34","doi-asserted-by":"crossref","first-page":"371","DOI":"10.1183\/20734735.018016","article-title":"How to keep good clinical records","volume":"12","author":"Mathioudakis","year":"2016","journal-title":"Breathe"},{"key":"2024122317355941500_ref35","doi-asserted-by":"crossref","first-page":"140","DOI":"10.1177\/1473779517709452","article-title":"The ill-informed: consent to medical treatment and the therapeutic exception","volume":"46","author":"Cave","year":"2017","journal-title":"Common Law World Rev"},{"key":"2024122317355941500_ref36","year":"2022"}],"container-title":["Postgraduate Medical Journal"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/academic.oup.com\/pmj\/article-pdf\/101\/1191\/76\/58954176\/qgae106.pdf","content-type":"application\/pdf","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/academic.oup.com\/pmj\/article-pdf\/101\/1191\/76\/58954176\/qgae106.pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2024,12,23]],"date-time":"2024-12-23T17:36:11Z","timestamp":1734975371000},"score":1,"resource":{"primary":{"URL":"https:\/\/academic.oup.com\/pmj\/article\/101\/1191\/76\/7743325"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2024,8,29]]},"references-count":36,"journal-issue":{"issue":"1191","published-online":{"date-parts":[[2024,8,29]]},"published-print":{"date-parts":[[2024,12,23]]}},"URL":"https:\/\/doi.org\/10.1093\/postmj\/qgae106","relation":{},"ISSN":["0032-5473","1469-0756"],"issn-type":[{"value":"0032-5473","type":"print"},{"value":"1469-0756","type":"electronic"}],"subject":[],"published-other":{"date-parts":[[2025,1]]},"published":{"date-parts":[[2024,8,29]]}}}