In brief
- Accept new referrals on a first-come, first-served basis, free from discrimination.
- Triage patients based on the urgency of their clinical needs. If you have a wait list, manage it to provide quicker care to patients with more urgent needs.
- Ensure patients on your wait list are appropriately monitored and know who to call if their condition changes.
- If you need to decline a referral because the patient requires care outside your clinical competence or scope of practice, assist the referring physician and patient by recommending an alternative care provider where possible.
Obligations for accepting new patients
As with all physicians, specialists’ (including family physicians where part or all of their practice focuses on certain specialty domains and includes referrals) acceptance of new patients is guided by the CMA Code of Ethics and Professionalism and by professional responsibilities as stated in College policies.
College policies on accepting new patients vary across the country, but generally require that specialists accept new patients on a first-come, first-served basis, free from discrimination. They also generally require that specialists take a number of factors into account, including the following:
- urgency and clinical need.
- wait lists.
- scope of practice and clinical competence.
Urgency and clinical need
Although not generally obligated to treat every individual seeking non-urgent or non-emergent care, specialists who receive requests to accept new patients should consider whether the patient needs urgent care.
The CMA Code of Ethics and Professionalism advises physicians to "provide whatever appropriate assistance you can to any person who needs emergency medical care."
College policies often advise specialists to address urgent or emergent situations similarly. For example, in its policy on accepting new patients, the College of Physicians and Surgeons of Alberta states, “A regulated member must provide care to the best of his or her ability to a patient in an urgent medical situation where no other regulated member is providing care, regardless of whether a physician-patient relationship has been established.”
Wait lists
With specialist care in high demand, many specialists have wait lists. Although the general expectation is to accept patients on a first-come, first-served basis, Colleges advise specialists to triage patients based on the urgency or seriousness of their clinical condition. Patients may need to be moved up the list if their condition worsens.
Managing a wait list and prioritizing appointments can be a significant part of a specialist's practice as new patients in various stages of illness are accepted and added to the list, and patients currently on the list experience changes in their condition. Some Colleges direct specialists to take relevant factors into account when prioritizing and monitoring wait lists, for instance the patient’s condition, and social factors that can influence health outcomes (e.g. housing, food security, employment, income).
Effective communication and understanding between the referring physician, the consulting physician, and the patient are valuable in managing a wait list. For instance, it should be clear to everyone who is the most responsible physician at all times, including when patients are waiting to be seen by a specialist. Patients need to know who to contact if their condition changes.
Specialists should also keep in mind the external environment, for example, government targets for wait lists. If a wait list is not close to the target, it may be necessary to decline referrals.
Even if a wait list is within the target, specialists should use their professional judgment to determine if they’ve reached their personal capacity and it’s necessary to decline new referrals.
Scope of practice and clinical competence
Specialists may feel they must refuse a new patient when they have restricted their practice or the patient requires care outside their clinical competence or scope of practice.
If declining a referral, Colleges generally expect specialists to quickly communicate the refusal to the referring healthcare practitioner and, if appropriate, the patient. This gives referring physicians and patients time to find another healthcare provider. When possible, some Colleges recommend that specialists suggest alternative providers who may be able to accept the referral.
Recognizing that some refusals can be seen as discrimination, some Colleges expect specialists to clearly and respectfully communicate the reasons for the refusal, thereby dispelling possible perceptions of discrimination. The refusal and the rationale should be documented by the specialist.
While a defined scope of practice is an acceptable reason for refusing a referral, it is not acceptable to use it as a means to discriminate.
Discrimination
Some Colleges are actively working to address discrimination and racism within the healthcare system and within their own regulatory structures. In addition to examining ways that healthcare can be provided in a culturally-sensitive manner, Colleges have expressed zero tolerance for racism and discrimination by physicians in every aspect of care, including when asked to accept a referral.
Many Colleges incorporate or refer to provincial or territorial human rights legislation when addressing discrimination in their policies on accepting new patients. For example, the College of Physicians and Surgeons of Nova Scotia’s policy states that physicians are bound by the Nova Scotia Human Rights Act, which prohibits discrimination on the basis of characteristics such as age, race, religion, sexual orientation, and gender identity.
Other College policies address forms of discrimination specific to healthcare. For instance, the College of Physicians and Surgeons of Ontario states that physicians cannot refuse patients with complex or chronic health needs, those with a history of prescribed opioids or psychotropic medications, those who require more time than other patients, or those whose injury, condition, or disability may require additional time for documentation and reports.
