In the medical home, pediatric providers (primary care pediatricians, general practitioners or youth health services) serve as the cornerstone for organizing and directing all aspects of children’s healthcare needs. (Fig. 1) When pediatric patients present with new health concerns, the pediatric provider must triage, assess risk, initiate indicated diagnostic testing and when appropriate refer patients to (sub-)specialists. To avoid undue burden on families and unnecessary testing and healthcare cost, it is essential for these pediatric providers to have the knowledge and skills to refer only patients at risk for pathology.

Fig. 1
figure 1

Generalized overview of pediatric care workflows. Please note: This overview may not be applicable to all countries

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Barriers may interfere with pediatric providers’ability to manage common pediatric conditions. These may include a lack of knowledge of signs and symptoms that indicate risk for pathology requiring subspecialty referral, and time constraints that preclude full diagnostic evaluation and/or effective communication with families to allay concerns when referral is not needed. To overcome such barriers national and international societies develop clinical practice guidelines and many of them have achieved this already.

In this journal issue, Stewart et al. describe a framework to simplify pediatric syncope diagnosis. The authors describe in detail the approach to a child presenting with syncope, possible causes and briefly describe the initial management of vasovagal syncope. The authors provide important elements in the history of present illness, family history, physical examination and basic investigations (electrocardiogram) that indicate risk for pathology necessitating a cardiology referral [1].

The authors should be congratulated for their efforts. Syncope is an anxiety-provoking complaint that is rarely related to a serious life-threatening condition. The authors rightly state that the use of a common framework such as theirs improves diagnosis and overall patient care. More specifically, use of such evidence-based guidelines reduces undue burden on families and unnecessary testing and healthcare cost. That being said, more work is needed to ensure that valuable guidelines such as this are disseminated and utilized and that the referral and consultation process results in improved patient care. To that end, we propose the following three action items: (1) development and dissemination of curricula to educate healthcare trainees on best practices in referral and consultation, (2) development of quality improvement (QI) initiatives to help reduce diagnostic testing and referral in patients with low probability of pathology, and finally (3) collaboration among subspecialists, pediatric providers, institutions and multicenter organizations to employ improved systems of communication and information exchange to enhance pediatric providers’ access to up to date information and guidelines.

Healthcare trainees need to be taught the medical knowledge and communication skills surrounding subspecialty referrals early in their career. Recognizing its importance, the American Academy of Pediatrics identified subspecialty referral and consultation as an entrustable professional activity that all residents need to be competent in by the time they graduate [2, 3]. Medical educators have identified steps needed to create new curricula to teach subspecialty referral and consultation skills. These efforts are focused on all aspects of referrals including (1) making appropriate referral decisions, (2) making the referral and ensuring its completion, and (3) providing appropriate post-referral patient care, coordination, and follow-up [3]. The team also developed tools that can be implemented at pediatric providers’ offices and subspecialty offices to gather feedback on the referral process and assess its appropriateness [4]. Harahsheh et al. were able to improve residents short-term syncope triaging skills as the percentage of residents who were confident about their decision to refer or not refer syncope patients to cardiology increased from 28 to 98% (P < .001). The overall self-efficacy of residents in syncope evaluation significantly improved from 69.5% ± 8.8% to 86.2% ± 6.2%, p < .001, and the Standardized Parents (SPs) ratings (mean) significantly increased from 61.1% ± 7.9% to 76.9% ± 5.6% p < .001 [5]. Stave et al. implemented a blended learning curriculum to improve communication skills surrounding subspecialty referrals. Pediatric residents participated in an interactive online module on syncope focusing on “red-flag” symptoms that necessitated a subspecialty cardiology referral and participated in an intervention with SPs, focusing on the communication skills. There was an overall improvement in communication skills based on SP scores (82.7 ± 10.9% to 91.7 ± 5.0%, p < 0.001). Residents’ improved performance enabled them to address patient/family emotions, explain referral logistics, and clarify concerns to agree on a plan [6].

Best practice in referral and consultation includes optimal collaboration with the families, a skill set which should be included in trainee and ongoing provider education. Patients and families are more likely to accept and follow through on management plans discussed and agreed upon. This information exchange requires the knowledge base and communication skills to effectively alleviate the parents/patients’ anxiety [7]. In children with chest pain 14% of unnecessary testing are related to parents’/patients’ anxiety [8]. Forest et al. reported that 16.7% of pediatric subspecialty referrals are made under the influence of parental request [9]. While parents’ anxiety is a driver for low probability referral and unnecessary testing, one needs to be careful not to treat the anxiety with a subspecialty referral. Interestingly, for some families, persistent anxiety even after cardiology evaluation occurs. Simunović et al. noted 38% of families of children with innocent heart murmurs were still concerned despite receiving a normal cardiology evaluation [10].

Reducing low probability referrals from pediatric offices can be achieved with QI initiatives. Harahsheh et al. implemented a chest pain decision support tool at local pediatric offices to help identify the red-flags for cardiology referrals. After multiple interventions, the team was able to reduce low probability referrals from 17 to 5% with no identified adverse cardiac events [11]. Similar QI projects are needed to help pediatricians manage patients with syncope and other anxiety provoking complaints. This is of importance as Tretter et al. showed that 60% of patients with benign (vasovagal) syncope referred to cardiology did not meet any red-flag criteria for referral [12].

Subspecialists also have a role in reducing diagnostic testing and referral in patients with a low probability of pathology. Managing expectations of referring providers and families may prove challenging in achieving this goal. Thus, education for current and aspiring specialists is key as well. Since subspecialists act as educators to the patients, families and referring practitioners, it is incumbent on them to avoid sending the wrong message to the referral base. It was shown that pediatric cardiologists ordered an echocardiogram in 23% of children presenting with chest pain with low risk for cardiac disease (no red-flags for referral) [8]. The consequences of unnecessary testing are multiple: (1) may increase the parents/patients’ anxiety, (2) increase health care system waste, and (3) identify clinically non-significant conditions which may further increase parents/patients’ anxiety. Conversely, establishing open lines of communication, such as provider-to-provider consultation before referring patients is a valuable tool in reducing low-probability referrals and unnecessary testing. This can be accomplished efficiently by establishing a system whereby pediatric care providers can send in a referral question before sending the patient, allowing the (sub-)specialist to provide guidance and/ or established guidelines to allow management in the pediatric providers’ offices. If the referral is made, clear post-referral communication from the specialist to the referring provider promotes optimal ongoing patient management.

In summary, clinical practice guidelines or frameworks are welcome tools to improve pediatric care but need reinforcement with new curricula for the future pediatric providers, QI initiatives and improved inter-provider communication.