[Patient initiative and referral decision of the primary care physician].
Using the German data of the European referral study from primary to secondary care this paper attempts to answer the following questions: which are the specialties GPs refer to, and which referrals were initiated by the patients. According to the study's methodology the gatekeeper function of the GPs or the patient initiative should be described by distinguishing between direct and indirect referrals. A direct referral is defined by a face to face encounter between patient and GP, while an indirect referral requires no such contact. For direct referral the GPs recorded the influence of the patient on their referral decision. In 71 practices (only the western part of the Federal Republic of Germany) 2077 direct and 1665 indirect referrals were documented. Every second direct referral was influenced by the patients. Women had a greater influence than men. An analysis by specialty showed that most of the direct referrals were directed to orthopaedics (14%), surgery (12%) and internal medicine (10%) and most of the indirect referrals to ophthalmology (25%), gynaecology (20%) and dermatology (8%) (64% of all indirect referrals were given to women). These results could be taken as an example how patients take over the responsibility of managing their complaints and illnesses by themselves in a health system with free access to specialist care. The role of the German GP as a gatekeeper and co-ordinator in the health care system turned out to be very limited. In consequence this might result in future problems such as a lack of co-operation, deficiencies in the continuity of medical treatment, over-medication unnecessary parallel investigations and additional costs.