Modern healthcare faces a plethora of challenges, including the efficient management of patient referrals. Many specialists, particularly in hematology, are noting an increase in unnecessary referrals, a trend that raises questions about the current state of healthcare practices. In the complex landscape of modern healthcare, an increasing trend of unnecessary referrals to specialists is drawing attention and concern.

Highlighted in a recent study by Dr. Benjamin Djulbegovic and Dr. Charles Greenberg from the Division of Medical Hematology and Oncology at the Medical University of South Carolina, this phenomenon underscores a systemic issue within healthcare practices. Their commentary, published in the journal “Blood Advances,” provides a critical examination of this referral pattern and its implications for patient care.

The study presents several case vignettes exemplifying the issue. A notable example is a 91-year-old man who traveled three hours for a hematologist appointment for advice on anticoagulation therapy, a decision that could have been made by consulting existing guidelines. Similarly, a young woman was referred for a potential blood cancer diagnosis due to anemia and thrombocytosis, a condition often linked to iron deficiency and correctable with proper treatment.

These instances reflect a broader trend in healthcare where patients are frequently referred to specialists for conditions that could be managed by primary care physicians or with easily accessible information. This pattern leads to what the authors describe as “hyper-fragmentation” of healthcare – the delivery of services across an excessively large number of poorly coordinated providers. As a result, patients often endure long wait times and undergo unnecessary procedures, contributing to inefficiency and increased healthcare costs.

“The lack of time is increasingly compromising clinical judgment competence, leading to unnecessary referrals and fragmentation of care,” Dr.Djulbegovic explain. This situation is exacerbated by the financial pressures on physicians to see more patients, further reducing the time available for each individual.

“The trend of increasingly referring patients to subspecialists pervades all specialties, not only our specialty hematology,” Dr. Djulbegovic state, emphasizing the widespread nature of this issue. They propose potential solutions to counter this growing problem. One such solution is the increased use of electronic consultations, which allow for rapid access to specialist advice and current guidelines, potentially reducing unnecessary referrals by more than half. They also emphasize the need for healthcare systems to incentivize providers to spend more time developing competence, thereby reducing the fragmentation of care.

In conclusion, this issue highlights a critical challenge in the healthcare system, where the quality of care is compromised by the overuse of specialist referrals for manageable conditions. The study calls for a reevaluation of current practices, urging for more efficient, integrated, and patient-centered approaches to healthcare delivery.

Journal Reference

Djulbegovic, B., Greenberg, C.S. (2023). Hematology referral madness syndrome. Blood Advances, 7(21), 6702. DOI:

Image Credit: Nick YoungsonCC BY-SA 3.0Pix4free

About the Authors

Benjamin Djulbegovic, MD, PhD is a Professor at the Medical University of South Carolina in Charleston, SC  at the Division of Medical Oncology & Hematology and Director of the Classical Hematology and Hematology Stewardship Program. His main academic and research interest lies in attempts to measure and optimize clinical research and practice of medicine by understanding both the nature of medical evidence and decision-making. To this effect, his work aims to close the translational research circle by integrating methods and techniques across evidence-based medicine (EBM), predictive analytics, health outcome research, and decision sciences with the goals of reducing overuse, underuse, and misuse of delivery of health services to improve patients’ health outcomes.

 Dr. Charles Greenberg is professor of medicine at the Medical University of South Carolina within the section of classical hematology in the division of hematology oncology. His primary academic interest is focused on hemostasis and thrombosis. His clinical practice has utilized telemedicine to serve patients in SC. His major basic science interest is in the structure of plasma and tissue transglutaminases. During his career, he was involved in the evaluation of new clinical laboratory tests  to assist in the management of patients experiencing hemostatic or thrombotic problems. His academic work has always focused on advancing basic and clinical laboratory advances directly to patients.