Referrals, Part 2

August 7, 2009

Some referral practices and rationales are quite logical, while others...let's just say they don't smell quite right. Even in my family practice group, where we have some restrictions, any reviews of the subject were usually met with discomfort. Still, I remained curious and identified 200 different specialists that my group referred to over the course of a year. So, why so many different referral docs?

Last time, I wrote about how formal discussion of this critical inter-physician relationship has too-often been avoided, except by the government’s heavy-handed attempt to reduce higher priced specialty care through the ill-conceived HMO gatekeeper legislation, and some multispecialty groups' internal protocols.

I also drew the distinction between a referral and a consultation, if only to note the difference in the breach. But the enormous costs involved in referrals and the significant impact on our patients' well-being would seem to invite a national, rational analysis, or a best practices study to provide firmer footing than merely casual personal preference.

Today, the point that I want to touch upon (dare I say the electrical socket) is the laissez faire, unexamined traffic among individual and small group private practice docs. I have personally seen a wide range of referral practices and rationales; some are logical and some don't smell quite right even though we do have restrictions, for example, on fee splitting. Let me know if you also have an amusing story to pass on or a best practices nugget.

In my family practice group we had few reviews of the subject. And even these were usually met with an uncomfortable "let's change the subject" attitude. Still, I remained curious and identified the number of different specialists that my group referred to over the course of a year. The number totaled an astounding 200!

So, why so many different referral docs?

First, in Silicon Valley, we have an abundance of specialists being near to both Stanford and the University of California at San Francisco medical schools. Our patient base was spread around quite a bit, certainly too much to maintain good communication flow with these docs, which is vital to our patients' well being.

Second, there are the patients who have seen a particular specialist in the past and it makes sense to send them back, if the need arises. That is, if the patient doesn't object, we can get the patient a timely appointment, and if there is still a concurrence of insurance possession and acceptance. If an unknown doc responsibly sends a prompt summary note, it is to everyone's benefit, and if the quality of service and the evaluation is very good, we'll add that person to our potential referral list. When docs who depend upon referrals do not send a summary note, one would hope they realize they are limiting their chances of getting another referral. But ignorance or arrogance often interfere in this presumably vital communication intended for the patient's best interest. You might be surprised how many referral docs from whom we never hear back (or get our patients back, for that matter).

After realizing the large number of docs to whom my group was referring, and the fragmented way in which it developed, I sent out personally addressed notes to each. I wrote:

Thank you for seeing our patients this last year. In the future, do you want more patient referrals, and if so, do you want all of their records, none of their records until after being seen, a brief summary of the patient's situation or some other way of facilitating the process?

Amazingly, even though we were the largest primary care group in Northern California at the time, I only received 37 replies. Answers to the basic question of "How can we primary care docs improve our professional contacts with you referral-based docs for our patients?" were amazingly diffuse. In other words, the results were ultimately counterproductive for our patients, for us and for the referral docs.

So I started asking primary docs and specialists individually their opinions and experiences. I heard of referrals based on who their tennis partner was, who was least likely to "steal" the patient, which surgeon invited them to scrub in most often, or who was a "good guy" in the hospital lunch room. Those were surprising but, to be fair, I also heard “So and so is the best, fastest, smartest, etc.”

Let's not give short shrift to the power of our office assistants either. Many referrals are made either by their personal preference or the ease of referrals with the specialist's scheduler. We're all busy. Paperwork and phone activity have us backed up and it’s natural to follow the path of least resistance rather than a rationalized process.

One true horror story with which to end. When I was getting to know doctors on staff I referred to them in turn, not knowing any other way to meet them and evaluate their work, other than hearsay. Coincidentally it used to be the practice in our community to receive small Christmas gifts from other docs. One January, I was walking down the hall of our hospital when I came upon a surgeon whose work had not impressed me and I had crossed him off of my list. He had given me a bottle of wine so I stopped to thank him as a courtesy. He grabbed my arm, looked up and down the hall, and said, "If you send me more patients this year, I will give you a better bottle of wine."

Sad, but true. Couldn't we find a way to do this better?