Identifying the problems, solutions, and challenges in referral writing: A Scoping Review

Introduction: Referral writing which is a source of communication between different colleagues, cannot satisfy the specialists and primary healthcare doctors.1 There is a need of identifying the factors that lead to this dissatisfaction. Many of these are discussed in literature such as communication skills, teaching and assessment of referral writings to undergraduates, and lack of a validated tool for evaluation of referral.2 This article is scoping review of literature for finding the problems, solutions, and challenges in referral writing. Materials and Methods: The databases utilized for finding various referral systems are PubMed, ERIC, Pakmedinet, and Google scholar. The 12 articles were included in the study, identified through PRISMA. These 12 articles were reviewed by two authors. (FA and TA) The first step was the application of Qualsyst criteria and then the two authors analyzed the final 12 articles for thematic analysis independently. Results: The problems, solutions, and challenges in referral writing were found after the thematic analysis by two authors. The multiple challenges regarding referral writing were, the inadequate data written in referral letters, lack of teaching and learning strategies, and lack of proper communication between physicians. There are many solutions like teaching and assessing the referral writing skills, introducing reflection and feedback to improve the skill among young doctors. Moreover, teaching the art of referral writing should include in the medical curriculum. Conclusion: Referral writing is an important part of medical communication. A good quality referral will save time in the management of patients. It will also enhance the outcome of patient management. There is a need for teachings communication skills in undergraduate and postgraduate students.


Introduction
The referrals are the source of information about patients for the specialist; management decision is again conveyed back to referring doctor based on this information. The outcome is proper care of the patient. 3 Good quality referral letters with complete clinical details result in a better consultation and communication between doctors and better management of patients. Proper communication between general practitioners (GPs) and specialists by systematic referral writing is a good indicator of improved patient care. Studies are done previously explained the various problems in referral writing but a very scanty amount of work was done at the national level in this respect. 4 Referral writing is recognized as a useful method of conveying detail about the patient and is a very effective way of keeping the patient's record. 5 There must be a proper system to establish systematic communication between primary and secondary care for the delivery of good patient's care. Referral letters are the best way to communicate and a good source of interaction between doctors. If the Referral letters are not written in detail the result in difficulty in diagnosis, care, use of unnecessary medicines, and laboratory workup. A detailed referral letter builds the patient's confidence in the doctor and leads to patient satisfaction. 6 According to the literature, the core principle of referral or consultation writing is to help the doctors from various specialties to communicate with each other for diagnoses and treatment of patients. The motive behind this is to provide the best possible care in their clinical settings. 7 There are several problems in referral writing and there are also solutions found in the literature. The best outcome can be achieved by addressing the challenges in referral writing and by improving the referral writing skills of junior doctors. There are multiple issues regarding referral writing not only in Pakistan but all over the world, and these problems lead to a delay in the care of patients. We need to identify these deficiencies and sort out the solutions for proper referral writing. 8 This Study helps us to identify the problems in writing a proper referral. It will also sort out solutions and challenges regarding the referral writings. Based on these findings, new strategies can be devised for proper referral writings which will not only improve the patient care and save the time spent in collaboration with other departments.

Search Results
Collectively, many studies were accessed in the form of journal articles, conference presentations, and dissertations through research databases and many of them were retrieved completely while abstracts of others were available on databases. Grey literature was also retrieved from Google Scholar. The main keywords were searched first separately and then they were mixed with other words related to theoretical background to find all possible literature available on various databases. The synonyms were also used to find out all possible related studies. Boolean Operators (AND, OR) were used as conjunctions to combine or exclude keywords in a search, resulting in more focused and productive results. Also, the snowball technique was used to collect more data to support the study. The last 5 years' articles were selected, and duplication was removed. The abstracts of selected articles were read carefully. The articles which were available in the full text were included and the rest of them were excluded. Most Relevant Studies Using Qualsyst The Studies having a Qualsyst percentage of ≥ 55% /score of ≥ 0.55 were included in critical appraisal. 9 This cut-off point was the lowest and below that, the study was not acceptable. This was followed by themes and code generation.

Results
Themes Identified after scoping review Themes related to problems of Referral letter: There are multiple barriers to the proper implementation of a systematic referral system. These include the formation of properly structured forms, provision of these forms in the workplace, and availability of time to fill these forms. Vargas et al.
(2018) discussed the important issues in writing referral letters in Latin American countries. These problems include the improper answer to the Referral letters and insufficient information given in the letters. One study showed that trainee feels lack of training in how to construct rhetorically relevant referral letters. 10 Although further research is needed, the care of the patient is markedly affected due to issues in referral letters. The proper Referral mechanism is required to solve these problems. 11 Lack of proper communication Lack of information in written communication between disciplines The findings of Lingard (2015) demonstrate that referral letter writing serves multiple purposes which include detail about the patient, building good interprofessional relations, and record keeping. Poor communication and lack of data written in the Referral letters affect the proper care of the patient badly by delaying diagnosis and doing an undue investigation for diagnosis. 12 Lack of quality content from primary health care system Most of the complicated cases are referred from primary or secondary care hospitals to tertiary care hospitals. The good interaction between these hospitals improves the health care system and makes it strong. The best way to interact is with help of a detailed referral letter. The precise Referral letter in which the treatment is mentioned properly helps to establish a diagnosis and decrease the number of medicines used. A properly written referral letter helps to increase the confidence level of the patient in treating the doctor. The consultants are not satisfied with the quality of referral letters. Medical students must be taught referral writing skills and it should be a part of the curriculum, according to a study by Ramanayake (2013), which has shown to improve the quality of referral letters. The use of mobile phone and social media increase the collaboration and improves the communication between various departments and physicians. This is the way to enhance and maintain the trust of doctors over each other. 13 Solutions to these problems for quality referral writing There are some solutions narrated in the literature. These include teaching and assessment of referral writings and undergraduates and postgraduate levels, providing structured forms for referrals, introducing e-referrals, and narrating clear objectives of referral writings. Adding a component of reflection in the teaching and learning process will be beneficial.
Regarding the management of patients with diabetes in Saudi Arabia, a recent study 14 described the importance of writing good and systematic referrals. Quality communication and availability of human and electronic resources are required for the referral system to work effectively. 14 One study showed that structured referral letters are better filled up by the trainees rather than writing on blank paper. 6 Providing detailed feedback on written/oral referral communication is an effective mean to improve the quality of referrals. 15 Prioritization of the referral of patients with colure coding will give a clear message about the urgency of the matter. 13 Referral writing curriculum The detailed Referral letters are an excellent source of communication between doctors and important information about the patient has been conveyed to the doctors. This skill requires time but unfortunately, it is not taught to medical students. This skill is not included in the curriculum and it's not part of the syllabus. The curriculum is already very much overloaded with subjects and topics that the department of medical education is not paying any attention to teaching this skill. According to Francois (2011), the referral writing skills can be improved by the self-directed learning of the students. The integrated system of medical education promotes self-directed learning, and the traditional system cannot enhance self-learning. Self-directed learning has a significant role in creating effective learners. 16 Indicators for quality improvement of referral The important components of the provision of good health care facilities to patients must be patientcentered and safe. The haphazard referral information has a bad impact on patient's health. According to Hartveit et al., (2017), there is a relationship between good referral with the care of the patient. The systematically written referral improves the management of the patient. Further workup is needed to prove this statement. 17 Challenges in referral writing A recent study (Kamau, Osuga, & Njuguna, 2017) conducted in Kenya found that there are multiple challenges in referral writing which include, manpower, financial constraints, and lack of proper infrastructure. Similar challenges are faced in other countries. If these challenges are dealt with primarily, this will improve the referral system. 18

Discussion
The purpose of this scoping review is to find solutions to the problems in referral writing and to address the challenges identified in referral writing. The most common problem is incomplete referral and insufficient information provided in referral. 11 This inefficient writing of referral letters leaves a bad impact on the communication about patients. This problem affects patient care. A well-organized and detailed referral letter is a good source of giving information regarding the disease of the patient. This is saving the time of the patient and doctors where the patient is referred. A patient has been saved from undue testing and repeated examinations. This helps in the satisfaction of the patient and good quality care. The amount of information provided through referrals is usually inadequate. The communication process must be strengthened to improve the quality of care of a patient. The consultants must do some telephonic conversation about the patient. 8 The incomplete and inadequate referrals are written by junior most doctors and usually lack proper use of the English language. The reason for writing such referrals is the unavailability of doctors and lack of time due to busy routines. There must be some properly designed structured referrals that help to save time and give detailed information regarding the patient. Most of the referral letters are written in very short form. The important patient information is missing in most of the letters. The referral letters are an excellent way of interaction between the doctors. The letters which are not giving details about treatment, diagnosis and examination finding cannot be a useful source of communication. 19 The letters have a strong impact on patient care if written in detail. There are lots of deficiencies and gaps in the content of referral letters. 20 If these gaps are overcome and referrals are written in a structured and systematic manner, the result will be improved healthcare. This is the answer to our research question with the help of scoping review as multiple problems and challenges are identified. Finally, the solution to these problems is also found through scoping review. Francois (2011) proposed the idea of a self-study module for the improvement of referral writing skills of students. The self-study module helps to cope with the situation of the already crowded curriculum of undergraduate students. This is the state of affairs in tertiary care and if we address the problems in referral writing from primary care again the lots of issues are recognized. Patients are referred without any information about their disease and investigations. The solution to this problem is making electronic referrals or structured referrals. 21 There is always a very good impact on patient care if the referral is written properly and in a detailed manner. 22 There are various problems in referral writing and there are possible solutions, but the real challenges are financial constraints to implement these changes. The real challenge to increase the workforce and to build proper infrastructure. 18 Various studies have been done with regard to referral writing. Most are related to deficient patient care, lack of communication between doctors, and delay in care. Others are identifying the problems in referrals. However, unfortunately, there is a very small amount of work done in Pakistan. The identification of problems in referral writing and the course contents of writing referrals also improves a student's learning. This, in turn, helps in writing good referrals and improves the system as a whole.
Limitations A multi-centric study must be done in Pakistan to highlight the issue of inappropriate referrals. More studies are needed to study the impact of good referrals on patient care.

Conclusion
This scoping review explored the different problems in referral writing and identified the solutions to these problems. The challenges are found for the improvement of referrals. I hope if these problems are addressed properly and if sincerely deal with the challenges; the output will be the organized referral writing. The organized referrals surely have a good impact on patient care. Referral writing skills can be improved by teaching medical students. Future recommendation: There must be a course for writing referrals and teaching this to medical students.