How doctors choose which specialists they refer to

There is an aspect of professional sports that I greatly admire. This transcends the athleticism and skill of the athletes, the work ethic, coaching expertise, teamwork and the thrill of the game. This is one of the only institutions that is a pure meritocracy. The philosophy is simple and not blurred by arguments for diversity or massaging the qualifications for admission to serve another agenda. Coaches, managers and owners want the absolute best performing individuals for the job. And so do the players. I wish this ethos were contagious to the rest of us.

The practice of medicine is not a meritocracy, either in the manner that students are accepted into medical schools, or in how we physicians practice. For example, what criteria do physicians use when they select a consultant? The ideal response is self evident. A consultant should be chosen because that specialist is the best qualified and is readily available to serve the patient. Medicine, however, is not an ideal universe. Consultants are not routinely selected solely for clinical skill. In my experience, availability trumps clinical acumen for many referring physicians who want their patients seen expeditiously.

These points apply to all physicians who consult colleagues, but primary care physicians are the primary source of specialty consultations.

Here are some reasons, beyond medical quality, why certain medical specialists are chosen.

• Reciprocity –- patients are referred in both directions
• Personal relationships
• Corporate enforcement keeping consultations within the network
• Economic pressure exerted by consultants to maintain referrals. I have seen this happen.
• Specialist willingness to do tests and procedures on request
• Habit
• Patient or family request

Even if a consultant is selected for some of the above reasons, the patient may still be ably served. For example, if a patient needs a screening colonoscopy, it does not matter that the gastroenterologist be a world class endoscopist. A simple community scoper, even one who blogs, may be sufficient.

In my experience, most patients receive high quality consultant care. However, patients are entitled to know that there may be unseen reasons why their physicians choose specific consultants. We specialists are not entirely righteous either. When we consult other physicians, we are also responding to forces that are under the radar. I personally admit to this in my practice.

When I entered private practice 10 years ago, after 10 years of a salaried position, I naively believed that conscientious care and availability would be a winning strategy to build my practice. I have learned that the dynamics between primary care and specialty physicians are more complex, and that the path to private practice success is not linear.

In sports, it’s all about winning. In medicine, it’s also about how you play the game.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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  • family practitioner

    rule number one: don;t be a jerk; if I think you are a jerk to me, then I will assume you will be one to my patients.

  • http://glasshospital.com GlassHospital

    I think this is a great post.

    It’s such a murky area, this “consulting/referring” relationship. I’m all about transparency, so I have a soft spot in my heart for docs who like to shine light into dark areas.

    Lastly, I can’t help but say I love the term “community scoper.” That’s a worthy blog title in and of itself. Maybe for your next act.

  • Primary Care Internist

    how about one who actually sends the referring doctor a report / opinion /assessment & plan / biopsy results etc.

    THAT is a dying phenomenon, and the tiny minority of specialists i refer to in NYC that do that, well they get all the referrals.

    • joe

      PCI:
      This is NOT a PCP vs specialist issue. I had THREE consults in clinic yesterday none of which with records. This is not without my office trying. Two of the PCP offices actually refused to send records without a release of records form, ON A PATIENT THEY REFERRED TO ME??? Seems like some people don’t really understand HIPAA. Don’t turn this into PCP vs specialist. This is about treating your referring or specialist colleagues with respect.

  • http://www.drjohnm.blogspot.com DrJohnM

    This post is an outstanding example of how the blogosphere can provide patients incredibly valuable information.

    Congratulations. Really good.

    In an instant, because a group of internists were purchased, a loyal referral source is changed. That is, except for the doctors themselves, or the families of doctors. “I take care of their parents, but their patients go to the specialists of their mother hospital,” said a specialist to me recently after a previously loyal group of internists was purchased by a competing hospital.

    Good work, Dr. K

  • Paknorr

    I am a consultant and like what you are saying! My issue is that most PMD’s don’t have a clue as to the quality of the consultant. Not sour grapes but a competitor donates to the hospital, is catholic, and is on many hospital committees. He spends all his free time in the Drs lounge. Lucky I’m too busy for that, but perception is huge. DrK

  • Jenga

    In medicine more and more it is what team you are on. These integrated systems drive referal patterns far more than anything else. It doesn’t matter how well you treat a PCP’s patient, for how long you’ve known them or are a regular Dr. Debakey. If they are bought by a system that has specialists that compete with you. You sir are hosed.

  • Max

    Any specialist who depends on a PCP referral to make his paycheck is looking for trouble. Depend on patient referrals instead. The PCP who would rather send his patient 30 miles away instead of the specialist in town is obviously worried about competition. The patients are not dumb. Drive 30 miles or go right in town. Hmm..i’ll stay in town. Now you have their whole family and friends and you can tell them what a moron that PCP is in proper parlance of course. Don’t depend on the PCP for referrals. Be nice to the patient, you’ll get them anyway. Trust me.

  • Anonymous

    Max you are wrong.
    If a pcp is sending his patient 30 miles away, it means 1 of 2 things:
    1. The doctor is affiliated in some way with the distant facility, although laypeople need to understand that this relationship is not directly financial. The doctor does not get a “kickback” for the referral (that would be nice albeit unethical). Rather, the doctor is being a “team player”; I can understand patients questioning this.
    2. The pcp, for whatever reason, does not trust this specialist. This is called clinical judgment. There may be quality issues, there may be bedside manner issues, there may be access issues. You should trust this judgment.

    Word of mouth is important, but so is the judgment of your primary care doctor. If you do not trust that judgment, then find a new one.

  • stargirl65

    How soon can you see the person? No one want to wait 6 months to see a specialist.

    How hard do you make it for my staff to send someone to you? There are 2 good gyn offices in town. One makes appointments on the phone while talking with you. The other one requests records to review first and then says they will call back for the appointment. Guess who gets more referrals?

    Is the doctor “nice” overall? There is an excellent dermatologist in town but he is kind of weird. Many patients do not like to see him.

    Can the doctor speak English well? I have some great ethnic doctors in my town with excellent medical skills. Unfortunately their accents are very strong and the patients do not know what they are saying. I often cannot follow what they are saying. This may not seem fair but is true.

    • LastoftheZuchinniFlowers

      While I appreciate your essential point, the sports analogy is flawed. The only reason ‘the best’ player is desired is because the ultimate goal is TO WIN, hence the motive is $$$$$ (profit). There is nothing INHERENTLY wrong with this. However, if you have been practicing for two decades then your surely acknowledge that health insurance (or lack of it) along with patient ability/willingness to travel are integral to specialist acceptance. I have offered referrals to specialists and supspecialists at ‘famous’ medical centers to patients only to be refused in favor of ‘someone closer to home? It’s NOT always about US. Nonetheless, I hear that you have been burned? I’m not surprised. I am old enough to remember the old school and while I’m soon to retire, will do a bit of this and that from time to time on a provisional liscense. Protocol,if you will, in medicine has changed so very much in my lifetime and not too much of it for the better. Time was you handed the patient the specialists phone number and THE PATIENT MADE HIS/HER OWN APPOINTMENT mentioning your name. That was enough – now acts of congress are needed prior to your patient being seen AND we have infantilzed the patient by doing EVERYTHING for them. In the attempt to avoid medmal. What a disgraceful assortment of controls we have allowed to co-opt our once self-directed and self-managed and time honored profession. While I’ll be glad to take down the shingle, I am also glad I was around for at least a part of ‘the golden age.’ Gone forever……… My kids? I am advising Orthodonia! Still essentially an autocracy and while some 3rd party interference, mostly $ up front.