BACKGROUND: Family physicians play a key role in coordinating and managing patient referrals to specialist care. While central to patient care, the referral process has been described as a disproportionately time-consuming and administratively demanding process, contributing to family physician burnout, stress, and attrition. Given the growing recognition of how administrative burden contributes to burnout, stress, and physician attrition from family medicine, it is crucial to examine the nature and impacts of this workload.
OBJECTIVE: To describe the range of perspectives and experiences of family physicians on the referral process.
METHODS: We conducted a systematic review of mixed-methods studies using a convergent integrative synthesis approach. Eligible studies were peer-reviewed, conducted in OECD countries, and published between 2012-2025. Quantitative data were transformed into portable narrative statements to enable integrated analysis with qualitative data. Constant comparative analysis was applied across different countries and study outcomes.
RESULTS: Thirty-one studies were included, conducted in 13 high-income countries. The referral process was characterized as requiring clinical, technological, and social competence, involving decisions about whether and how to refer, and constructing and following up on referrals. This work was further complicated by strained and fragmented healthcare systems, positioning family physicians in the role of bridging system gaps for patients. These challenges resulted in additional paperwork, unnecessary referrals, delays, and rejections, which exacerbated system inefficiencies as opposed to improving resource use. Ultimately, this contributed to physician burnout, reduced professional autonomy, and job dissatisfaction.
CONCLUSIONS: Ameliorating referral-related burden will require system-level reform and examination of intra-professional power structures.