When should a patient be referred to a specialist?
Primary care physicians may consider referral to specialists when they need additional expertise or are out of their “comfort zone” in treating a patient with diabetes.
All patients with diabetes should be referred to an ophthalmologist for a dilated eye exam. Primary care physicians may consider referral to an endocrinologist when they are out of their “comfort zone” in terms of therapeutic options or practice resources.
Consider referral to the appropriate subspecialists when a patient:
- Fails to reach target hemoglobin A1c within a reasonable time period (six months).
- Develops diabetic complications including nephropathy, cardiovascular disease, gastroparesis, etc.
- Suffers unexplainable blood sugar fluctuations.
- Has severe or recurrent hypoglycemia.
Excellent communication is key for successful collaboration between generalists and specialists in diabetic care. When a referral is made, remember to clearly define the question/problem that should be addressed. The specialist should, in turn, provide clear documentation about what changes in management have been recommended. If a specialist makes a change in medication that requires laboratory follow-up, the specialist should make sure that the appropriate tests are ordered and completed and that the results are followed up with the patient. If specialist resources are scarce, innovative models have been successful, such as having a specialist provide assistance and additional expertise as part of a diabetes expert care team (e.g., a diabetologist and a nurse-certified diabetes educator) that sees patients jointly with primary care team.