The Referral That Should Not Have Been Made
You are a psychologist in an integrated primary care clinic. A 58-year-old patient, Ms. Iqbal, presents with six weeks of low mood, early morning waking, 8 kg weight loss, and new-onset low back pain. Her GP has referred her to you for 'depression, start CBT.' You notice from the shared record that she has not had bloods in two years, has a family history of pancreatic cancer, and has never had imaging for the back pain. She mentions she has stopped eating much because of nausea. The GP is on leave for three weeks and the clinic is short-staffed. Ms. Iqbal says she just wants to talk about her mood.
1. Should you proceed with CBT as referred? Justify your decision and identify what needs to happen first.
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Proceeding straight to CBT as referred would accept a formulation that the data do not yet support. The combination of new low mood, marked unintentional weight loss (8 kg), nausea with reduced intake, early morning waking, and new back pain in a 58-year-old with a family history of pancreatic cancer is a red-flag constellation that warrants medical investigation before or alongside psychological treatment. That does not mean the depression is not real or that CBT is inappropriate; it means the referral question is incomplete. The competent response is to act on the medical findings: escalate to the covering GP or duty clinician the same day, specifying the red flags and requesting bloods and clinical review of the back pain and weight loss, and document the escalation. In parallel, you can begin engagement and supportive work with Ms. Iqbal, explaining that mood and physical symptoms are connected and that ruling out physical causes is part of good care, not a rejection of her request. Withholding all input until the GP returns in three weeks would be an unnecessary delay; substituting psychological treatment for medical workup would be a scope error.
2. Ms. Iqbal says she only wants to talk about her mood and does not want 'more tests.' How do you respond, and what are your limits?
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Respect autonomy while being clear about the boundary. Explain in plain language why the symptoms matter: weight loss, nausea, and new back pain are not explained by low mood alone, and a small number of simple tests can rule out treatable physical causes; if they are clear, the psychological work can proceed with more confidence. Explore the reluctance - fear of results, cost, previous bad experiences, or fatigue from being investigated - because the reason shapes the response. Offer to make the process as small and concrete as possible, and involve her in choosing the order of steps. Then state the limit honestly: you can and will work on her mood, but you cannot provide psychological treatment as a substitute for investigating symptoms that need medical assessment, and you will need to share the concern with the medical team. If she declines all investigation, that is her right, but document the discussion, the advice given, and the plan to revisit. Do not coerce, and do not collude with avoidance.
3. The covering GP is junior and asks you to 'just do the CBT and we'll sort the medical side later.' How do you handle the interprofessional disagreement?
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Handle it as a clinical safety issue, not a territorial one. Restate the specific findings and why they matter, in the terms a medical colleague will act on: unintentional 8 kg weight loss, nausea with reduced intake, new back pain, family history, and no bloods in two years. Make a clear, documented request: clinical review and baseline investigations, with a timeframe. Where the disagreement persists, use the escalation route the clinic already has - the duty or on-call GP, the clinical lead, or a same-day huddle - rather than allowing the case to drift. Record the request, the response, and the escalation, because the record is what protects the patient if the concern is later vindicated. Continue psychological input in the meantime so the patient is not abandoned. Afterwards, raise the pattern at a team level if referrals routinely omit medical workup, since this is a system issue rather than one junior clinician's judgement.