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Family Medicine Survey

Please note that for the following questionnaire we will specifically be asking about referrals to internal medicine. This includes general internists and any subspecialist within internal medicine (cardiology, rheumatology, endocrinology, respirology, nephrology, hematology, medical oncology, geriatrics, infectious diseases, gastroenterology and immunology/allergy).

1. Are you male or female?

2. What year did you graduate from medical school?

3. Is your family medicine practice hospital-affiliated?

If you answered yes to the question above, which hospital is your practice affiliated with?

4. How large is the roster size of your family medicine practice?

5. What model of care best describes the organization of your family practice?

Please enter an 'other' value for this selection.

6. How many patients do you see in an average clinic day?
(Please provide a single number estimate)

7. What percentage of patients in your practice would you consider complex (i.e. have multiple medical comorbidities)?
(Please provide a single number estimate)

8. In an average week, how often would you say that you initiate a new referral to an internal medicine specialist?

9. How do you most commonly communicate these new referrals?

Space Cell	Always never	Rarely	Sometimes	Usually	Almost always
Fax	Fax: Always never	Fax: Rarely	Fax: Sometimes	Fax: Usually	Fax: Almost always
Telephone	Telephone: Always never	Telephone: Rarely	Telephone: Sometimes	Telephone: Usually	Telephone: Almost always
E-mail	E-mail: Always never	E-mail: Rarely	E-mail: Sometimes	E-mail: Usually	E-mail: Almost always
Mail	Mail: Always never	Mail: Rarely	Mail: Sometimes	Mail: Usually	Mail: Almost always
In person	In person: Always never	In person: Rarely	In person: Sometimes	In person: Usually	In person: Almost always
Book directly into specialist clinic	Book directly into specialist clinic: Always never	Book directly into specialist clinic: Rarely	Book directly into specialist clinic: Sometimes	Book directly into specialist clinic: Usually	Book directly into specialist clinic: Almost always

10. How do internal medicine specialists most commonly communicate the results of their consultation to you?

Space Cell	Always never	Rarely	Sometimes	Usually	Almost always
Fax	Fax: Always never	Fax: Rarely	Fax: Sometimes	Fax: Usually	Fax: Almost always
Telephone	Telephone: Always never	Telephone: Rarely	Telephone: Sometimes	Telephone: Usually	Telephone: Almost always
E-mail	E-mail: Always never	E-mail: Rarely	E-mail: Sometimes	E-mail: Usually	E-mail: Almost always
Mail	Mail: Always never	Mail: Rarely	Mail: Sometimes	Mail: Usually	Mail: Almost always
In person	In person: Always never	In person: Rarely	In person: Sometimes	In person: Usually	In person: Almost always
Not at all	Not at all: Always never	Not at all: Rarely	Not at all: Sometimes	Not at all: Usually	Not at all: Almost always

11. How satisfied are you with the amount of time it typically takes for an internal medicine specialist to communicate their opinion to you following your initial referral?

12. Which internal medicine specialities do you think are the most difficult to access for initial consultations?
(Please check all that apply)

13. In your opinion, what percentage of new referrals that you make to internal medicine specialists would be avoided if you could communicate directly with an on-call specialist by phone or e-mail for advice?
(Please provide a single number estimate)