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BACKGROUND: Because it is possible that part of the variability in frequency of interventions and even in outcomes results from the variability in referral patterns of primary care physicians, our objectives were to examine primary care physician decision making about referrals for several common adult and childhood conditions. METHODS: One hundred thirty-six family physicians in 80 office-based practices recorded reasons for referral to the most common types of specialists and the expectation of the specialist for conditions with at least seven referrals to each specialist. RESULTS: By far the most referrals were expected to be short-term (< 12 months); for more than 50%, the referrals were for consultation only (rather than direct intervention). For most of the 10 types of conditions, there were no apparent differences in reason for or expectation of the referral that would explain the choice of different types of specialists for referral. Expectations for shared care were generally more common in referrals to nonphysicians than to physicians. CONCLUSIONS: This study revealed unexplained variability among family physicians in the specialists to whom patients are referred for specific conditions. Why some patients with the same condition are referred to surgeons and others to medical specialists is unclear, at least in the context of expectations for referral as being long-term vs short-term or consultative vs referral for definitive management. The impact of this variability on costs and outcome could be considerable and deserves more intensive study.