'Is psychiatry now a sub-specialised field?': GP asks why his referrals are being rejected

A GP has spoken out about his increasing frustration at having his psychiatrist referral letters rejected because his patients are too old, too young, or at risk of suicide.

Dr Andrew Leech says he has penned his open letter to all psychiatrists in an attempt to understand why it has become “the norm” for his referrals to be knocked back.

He said some psychiatrists had refused to accept his patients with a history of ADHD, autism, eating disorders, personality disorders and PTSD.

Psychiatrists had also said no to patients because they were under — or over — the ages of 15, 16, 17 or 18.

Writing on the RACGP website, he said one of his referrals was rejected because the psychiatrist did not see patients with a history of suicide attempts, recent hospitalisation or patients who were currently at risk.

While acknowledging that psychiatrists were under stress and dealing with a “massive uptake in new referrals”, he stressed that GPs were also fighting what felt like a “losing battle” with an increase in acute presentations, eating disorders and self-harming behaviours.

“I need to say, these letters leave me with mixed feelings; confusion, frustration, helplessness and ultimately sadness for the patient, who deserves better care,” the Perth GP wrote.

“These are people we know well and for whom we have used everything in our general practice ‘toolkit’ to manage.

“By this point we’ve usually already tried the first, second and third-line treatments just to avoid the need to refer. We’ve hit a wall and so has the patient.”

Dr Leech went on to say GP colleagues had suggested to him that detailed referrals may be part of the problem, and doctors would have a better chance of their letters being accepted if they were “dumbed down”.

“What would allow us to be heard so that we can get help when we need it?

“Is psychiatry now a sub-specialised field, similar to orthopaedics, whereby they cannot see anything even remotely outside their scope of practice?”

Dr Leech said the hardest part was telling patients the referral had been rejected.

“They are often deflated, naturally feeling it is their own mental health diagnosis that is part of the problem when it comes to getting help.”

He concluded that he hoped his letter would lead to interim solutions, such as greater use of Medicare Item 291 — allowing a one-off visit and management plan — or more reliance on telepsychiatry until more psychiatrists entered the workforce.

“I’m not trying to complain, I have many psychiatrist friends and respect them highly,” he said.

“Rather I want to understand the situation and what we need to do, so we can work together to make the lives of our patients easier.”

Dr Leech’s open letter to psychiatrists

To my respected psychiatry colleagues,

Firstly, I want to thank you for the hard work and dedication you have provided to some of our most vulnerable patients.

I can’t imagine what it is like to deal with the massive uptake in patient referrals, emergency presentations and increased complexity in diagnosis and treatment. Likewise, the stress that this can lead to and the pressure you must be under both in the public and private sector needs acknowledgement.

However, we’re all on the same journey, and with mental illness prevalence surging in Australia right now it can sometimes feel like we’re fighting a losing battle.

In general practice we’re seeing escalating levels of risk, more acute crisis situations, longer consultations, ADHD presentations, eating disorders, increased self-harming behaviours, higher rates of drug use and social problems, more anxiety and a huge demand for appointments with a general sense of stress and burnout in patients of all ages.

So, it’s within this context that I wish to raise a few concerns that have become ‘the norm’ in my experience when referring patients to psychiatrists over the past year or so.

Below are the top five responses I’ve received in recent times, all of which were part of a generic rejection letter:

The psychiatrist does not accept referrals for patients with a history of ADHD/autism/eating disorders/personality disorders/PTSD and so on
The psychiatrist does not accept referrals for patients under the age of 15/16/17/18 — or vice-versa, they don’t accept referrals for patients over 15/16/17
The psychiatrist does not accept a referral for a patient with a history of suicide attempt, recent hospitalisation or who is currently at risk
The psychiatrist will see the patient once for an assessment, but not prescribe and send the patient back to the GP (prompting a subsequent search for another psychiatrist)
The group of psychiatrists have reviewed your referral and don’t have any suitable for your patient at this time

Then, at the bottom — ‘please inform your patient of this outcome’.

I need to say, these letters leave me with mixed feelings. Confusion, frustration, helplessness and ultimately sadness for the patient, who deserves better care.

These are people we know well and for whom we have used everything in our general practice ‘toolkit’ to manage. By this point we’ve usually already tried the first-, second- and third-line treatments just to avoid the need to refer. We’ve hit a wall and so has the patient.

Which brings me to my point: I know you are busy — but why are we getting these answers?

Whether it be that books are full, or psychiatrists are sub-specialising, I feel GPs need to understand why this is happening and how we can work to help you, so that you can help us.

When I receive rejection letters, I often ring specialist rooms to explain the importance of getting help, to advocate and explain the urgency.

And I’m not going to lie, by this point I’m frustrated. But the hardest part is having to then explain it to the patient.

They are often deflated, naturally feeling it is their own mental health diagnosis that is part of the problem when it comes to getting help.

I like to write detailed referrals for all specialists, to make it easier and reduce the need for doubling up of work. However, talking to colleagues, perhaps providing this level of detail is actually to our disadvantage, and a ‘dumbing down’ of the referral would have more chance of getting accepted.

What would allow us to be heard so that we can get help when we need it? Is psychiatry now a sub-specialised field, similar to orthopaedics, whereby they cannot see anything even remotely outside their scope of practice?

These are questions that come to mind as I grapple with these ever-increasing challenges.

In any case, I hope this letter helps you see things from our side and leads to solutions, whether it be greater use of the Medicare item 291 (allowing a one-off visit and management plan), or more reliance on telepsychiatry services, at least in the interim until more specialists become available to help the workforce.

I’m not trying to complain, I have many psychiatrist friends and respect them highly.

Rather I want to understand the situation and what we need to do, so we can work together to make the lives of our patients easier.

More information: newsGP; 23 August 2023