Why more primary care doctors are referring patients to specialists

Why more primary care doctors are referring patients to specialistsAccording to a recent study from the Archives of Internal Medicine, primary care physicians are referring more patients to specialists than ever before. In fact, the rate almost doubled in the 10-year period between 1999 and 2009.

This drives up the cost of care, as specialist consults tend to be more expensive than primary care visits.  Furthermore, specialists tend to order more advanced diagnostic tests.

It’s pretty easy to see why this is happening.

Back in the days of capitated care, there was pressure from HMOs to reduce the amount of referrals, as doctors were given a set fee to manage each patient. A referral meant a financial hit to the practice.  But the HMO model was rejected by patients, who didn’t like their choice restricted and accused doctors of holding back care.

So, fee-for-service medicine continued to grow, and there was little incentive to scale back referrals. In fact, as a New England Journal of Medicine study revealed a few years ago, the Medicare patients saw an average of seven doctors: 2 PCPs and 5 specialists.

According to the lead author of the Archives study, Dr. Bruce E. Landon,

… medicine has become more complex, with specialists and subspecialists seen as expert in the latest treatments. “Medicine is becoming increasingly technologically sophisticated,” he said in an interview.

But Dr. Landon also points to the “tyranny of the 15-minute visit,” during which the average primary-care physician does not have the time or resources to delve into any potentially complicated medical condition.

The last point rings particularly true. As patients become more complex and time pressures grow, many doctors simply take the path of least resistance and refer out.

Sarah Kliff, who blogs at the Washington Post’s progressive-leaning Wonkblog, adds that money is a factor:

… part of it likely has to do with the economics of referrals: Doctors who have an ownership stake in their practice are 50 percent more likely to refer to a specialist, which would increase the total revenue generated by a given patient.

That’s dubious.  I don’t have a financial incentive to refer to specialists.  Most of my colleagues don’t either.  And with more doctors exiting private practice and into salaried hospital positions, that reason will become less relevant.

I’ll add one more reason that hasn’t been mentioned: defensive medicine. Although the threat of a malpractice lawsuit is typically associated with ordering potentially unnecessary tests, making a specialist referral is simply another variation. When primary care doctors see “failure to refer” as one of the leading reasons why they get sued, it’s no wonder why more are doing so.

Physician behavior is governed, to a large degree, by incentives. Given the incentives that doctors face in our health system today, there’s little surprise why more are referring patients out to specialist care.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.facebook.com/rob.lindeman1 Rob Lindeman

    Regarding Sarah Kliff’s comment, it’s worse than dubious, it’s spurious.  There is no financial incentive for primary care docs like us to refer out. I’ll ditto the defensive medicine piece.  But primarily, the drivers are probably time and productivity: We need to spend more time managing our own patients.

  • http://www.facebook.com/RebeccaCoelius Rebecca Coelius

    States like Washington have a culture of Family Docs and other primary care specialities practicing full scope medicine even in urban areas, in populations both wealthy and poor, with outcomes equivalent to the rest of the country but for less money. 

    Cost savings with equivalent or improved quality is precisely what the Center for Medicaid/Medicare Services is looking for. There are few other solutions so obvious and straightforward. This should be mentioned about every single time an article is written about fixing our health care system, but its not. Its not just about increasing the number of primary care doctors, its using them inappropriately and having all physicians work at the top of their license. (Nurses did an amazing job creating this concept). 

    Can we use our collective connections and power to get a well written article about this on the front page of a paper like the NYTimes? Americans need to stop seeing primary care docs as gatekeepers or too incompetent to handle any real medicine, and instead believe in us as the leaders in fixing our costly, ineffective health system. 

  • Anonymous

    Wow. This is amazing. I thought it was advanced practice nurses who refer to specialists more because of their lack of knowledge and inability to distinguish normal from abnormal. What can be said about the ability of the primary physician to save healthcare dollars by preventing unneeded referrals? And what about the “need” for your “supervision” to prevent those APNs from – making unnecessary referrals? It seems you should work on yourselves first, yes? Yet another reason your “supervision” is not necessary. We collaborate with specialists such as internists, orthopedists, surgeons; we send them x rays and ask them questions. We splint in the office, remove lesions in the office, biopsy in the office, suture in the office, cut toenails in the office. We get on our feet and MOVE as NPs like we learned to do/HAD to do as registered nurses. We never sit down in our private practices and we only refer when necessary and always COLLABORATE when needed. This is an eye opening piece. From what I read from many critical family practice physicians, the title should have read “Advanced Practice Nurses” and not “Primary Care Doctors”. More proof to me we are doing things right. Bravo Dr. Pho – great article! And thank you for letting me speak my mind.

    • Anonymous

      referrals from NPs to specialists i have witnessed:

      1- ecchymosis in pt on coumadin referred to derm

      2- creatinine bump from 1.0 to 3.6 after starting lasix for pneumonia

      3- cardiology for well-managed euvolemic chf, htn, a.fib on multiple meds (seen this many many times)

      4- pulmonary for controlled asthma

      5- endocrine for hba1c=7.5

      6- ent for self-limited nosebleed in a nose-picker

      the list goes on and on. 

      And yes, i know that some MDs practice this way, but this is way way more frequent in the undereducated mid-levels, from what i have seen.  And frankly the attacks on primary care docs is really getting annoying. Who do you think has to be reachable after hours - the midlevel or the doctor?

      • Anonymous


        You wasted 6 lines of response with anecdotal evidence – those examples mean nothing. They are, quite frankly, pathetic and speak volumes about you. and then you freely admit some physicians practice this way as well. So not sure where you are coming from there.

        I too, am sick of the attacks on advanced practice nurses. So you and I are on the same page. You say the things you say “undereducated”, “mid-level” knowing clearly that it is offensive to advanced practice nurses. You do not care – it matters not to you. And it matters not to me. You have pushed and pushed and demeaned and it is coming back to haunt you. Call me advanced practice nurse or nurse practitioner sir. I will call you physician or doctor if you wish. I have a choice of title just as you do; but you will never change. You show your true colors.

        Finally, reaching who after hours? What cave have you been practicing in? I own my own private practice nurse managed clinic – opened and financed ALL with my own private funds. I gained the the trust of patients on my own and I am credentialed with all major insurance companies on my own. I take ALL of my after hours calls. A physician has never even been in my clinic (except as a patient).

        So, you know what you are doing – you inflame but don’t appreciate being inflamed. When you change, I will.

        Anything else?

        • http://pulse.yahoo.com/_GXO5UT3MGTPBRYKXHHFG6NCRO4 S

          Not a word about NP’s in kevin’s thread. The issue was lack of time. You are “sick” of an attack where none is present? I think the one showing his/her true colors is you.

          • Anonymous

            I understand your point S. The attacks are relentless on NPs and this was an excellent example of how physicians are just as guilty of over-referring as APNs, yet over-referring is one of the “dangers” they assign to us as we waste too many health care dollars. It immediately caught my attention (obviously). So, that is where that diatribe originated. There really is no difference between “you and us” in that area. My accusations of attacks are cumulative. Sorry for the misunderstanding.

        • Anonymous

          I didn’t know “midlevel” is derogatory, and certainly didn’t mean it as such.

          And “undereducated” literally, compared to physicians you claim to be ABOVE, is true, and shouldn’t offend. It means that you have less education than a doctor – do you disagree?

          It seems to me that your need to be addressed a certain way is driven by insecurity.

          I do, in fact, work with some wonderful NPs, none of whom display the arrogance you do. When confronted with a difficult clinical situation, they first discuss it with me, their supervising (or collaborating, if you like) MD.  And if it’s something i’m not comfortable managing, then we can in turn consult a specialist physician. Simple as that. Not a pissing match, just good old primary care.

          • ProudOkie


            I appreciate and understand your retort. A few comments:

            1) I don’t claim to be above you. I simply have the education to operate WITHOUT a primary care physician. Neither one of us can operate with specialists so we are in the same boat. I respect other professions when they respect mine. APNs are always spoken of by physicians in the “collective” as mid-level, revenue enhancer, extender, etc. These are all terms originating from your profession. We prefer NP. Notice in the future as you read blogs and articles on the web that these terms are used intentionally.

            2) You have misinterpreted opposition for arrogance. I seem arrogant as opposed to your NPs probably because they come to you, defer to you, and treat you with the respect you believe you deserve. That respect probably originated with them so you are okay with it.

            3) I mentioned in my post I do collaborate and probably more efficintly than most primary care physicians – send radiographs and EKGs (when needed) instantly via iphone to the specialist, hotline to the surgeon, etc.

            4) Finally, insecurity? I live the American dream daily as a nurse practitioner. I own my own RURAL practice, no employer (insurance companies, medicare and medicaid), an unbelievable living, reasonable expenses, an NP partner, TWO registered nurses on staff, and more patients than I can handle. I love reading blogs and love kevinmd.com. It gives me lots of insight into the mind of the physician. I can still see you see us as threats when we are NOT that at all. But that leads us back to the old argument of independence. As long as you are seen as the leader of the pack then things are okay. Outside that belief, all hell breaks loose.

            I respect physicians fully – couldn’t practice without them. I just interact with some more than others – tried to interact with family practice physicans in my area; as you would obviously expect, they wouldn’t have it. So I just carry on successfully without them. So in all of this what do I expect? (I know, who really cares?)  Leave me alone to practice – that’s it. Nothing else. Can you agree to do that? Can you let me stand or fall on my own? Can your profession focus on you and let me succeed or get sued into oblivion on my own? 

      • liz mangieri

        Kjindal and others, while I hear your disdain, please acknowledge that NPs have been innundated with remonstrations for NOT sending on precisely that patient who ‘might’ have had severe dz though not likely from the group above.  Many, many, many times in our derm practice, referrals from IM/Primary Care for evaluations of ‘suspicious’ lesions which required basic 2-3mm punch biopsies kept us routinely busy.  How many IM/Primary Care guys/gals do their own simple biopsies today?  How many know how to evaluate a pigmented lesion with a dermoscope?  Is this a primary care skill?  Why or why not?  And we KNOW that dermatologists will call you a ‘non-dermatologic provider/physician’.  Take home? We must all do what we can, SAFELY and within the limits of our skill set, within the time we are allotted.  I really don’t think the issue is more complex than that.  There are brilliant and marginal physicians just as their are NPs/PAs/surgeons/podiatrists/ad infitinitum-fill in the blank. Most IM/Primary Care professionals will render the services they are comfortable providing.  In some practices there is a guy or gal who can do things outside the box of their specialty but is reluctant to do so given the confines of the practice parameters.  This is unfortunate, but the reality of our very litigious society.  Case in point:  IM/PC can no longer rx Accutane.  Should they EVER have been doing it?  Why or why not?  Again the conundrum persists.  Medical specialties can be their own worst enemies as we now hear derms (once booked six months out with all the up-front $ cosmetic patients crowding the office) rightly assigning self-blame for permitting this debacle.  Never too late to change behaviors.

  • http://onhealthtech.blogspot.com Margalit Gur-Arie

    Shortage of time is probably the number one driver for independent primary care doctors. However, primary care physicians who are practicing in large multi-specialty groups and refer to their partners do have a financial interest to refer since the specialist is paid much better. This may be what Ms. Kliff meant.
    In addition to that, as more PCPs are owned by hospitals and health systems with specialty services, they too are probably compelled to help boost revenues for their employer by referring, not out, but in. I thought this was one of the main reasons large systems are buying, and losing money on operating, primary care practices.

    Unfortunately, Rebecca, the consolidation brought on by ACOs and such, will only increase dependence of PCPs on these for-revenue systems. Without fully functioning independent primary care, costs can only go up.

  • Anonymous

    As a Lean Six Sigma process guy working in hospitals I can’t help but wonder if this is a good thing.  One of the most common things I hear from frontline staff is that each patient is so “different” that there is no way to standardize care.  By grouping patients by diagnosis early in the process rather than late I would expect that there is the possibility for higher quality and higher efficiency much in the same way we see huge gains by using split-flow in the ED.

    I don’t have much experience with the doctor side of the process – does this ring true for anyone?  Are there costs on the part of the specialists due to a more varied patient mix that would increase if referrals dropped?

    • Anonymous

      Hi Brad,

      Most patients are NOT “so different”. Most patients are the same. The need for a referral is obvious in the majority of cases: an obviously specialized disease that needs specialty care. Other than that many many referrals are useless and are because: 1) the primary provider does not know how to perform a particular procedure within their scope, 2) the provider feels they have no time to perform a procedure or manage a disease, 3) the provider feels a specialist should manage the particular issue, or 4) the provider is lazy or “too good” to manage a disease or perform a procedure. The key as a primary provider is to be able to recognize the small percentage of patients with abnormalities that actually need referral. Hope that helps!

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    We should be referring when we want an expert opinion. We refer if we feel the disease entity is confusing and we need help. We refer if the workup require a procedure to be performed that our training  or hospital bylaws do not consider us qualified to perform. We refer if the patient asks for another opinion. I see a different pattern. I see patients who start out seeing a specialty physician for an abdominal problem. They mention that they have a headache and are sent to the neurologist instead of back to the PCP who referred them in the same place.At the neurologist the complain of difficulty hearing and get sent to the ENT rather than to the original PCP. At the ENT they complain that the stairs leading up to the office were steep and they got winded. The ENT refers them to the cardiologist and pulmonologist. By the time they get back to the PCP they have seven new doctors all of whom asked them to return in three months forever.

  • Michael Kirsch

    Aren’t some of the referrals driven by the patients?

  • http://www.facebook.com/people/Erika-Bliss/1363813483 Erika Bliss

    Very interesting article, and it confirms what we have found at Qliance in Seattle, where we do a type of practice called the Direct Primary Care Medical Home (DPCMH).  In this model, patients pay a flat, low, monthly fee based on age (we do not bill insurance), and in return receive unlimited access to office, phone and email visits, extended office hours, weekend hours (including Sunday!), in-office diagnostics (including X-ray), office procedures, first-fill generic medications, all at no additional cost.  And there are no per-visit fees.  In other words, no disincentives to the patient to come in for care and use us as much as they need or want.  Without the negative incentives of the fee for service system, which drives us to do more, not better, and the costly overhead of insurance billing (insurance is great to protect you against the risk of a catastrophic event, but not so much for paying for routine, expected things — it’s like having car insurance to get tune ups and oil changes), we can have smaller panels and spend more time with our patients (30-60 min appointments).  What we have found is that, when patients have enough time with their doctors or nurse practitioners (we have both!) and the provider can listen to their whole story, ask a lot of questions, do all of the necessary physical exam items, and even look up information or call specialists for input, patients are referred much less for specialist care (or for advanced radiology, hospital care, ER care, or surgery for that matter), and the patients are HAPPY about it!  Our preliminary data shows that we consistently lower ER utilization by 65%, specialist visits by over 50%, hospital days by 45%, advanced radiology by over 50%, and surgeries by over 80%.  All that without a single disincentive program in place to try to control provider referral behavior.  And, our providers and staff track every referral from beginning to end, so we don’t have the situation very often where a patient is bounced from specialist to specialist, because we are on top of what is happening with them and they see us as their medical home. The bottom line is, there is no substitute for time when you are developing a relationship.  Who among us would consider someone a trusted friend after a 5 minute conversation where the other person interrupted us after just a few seconds?  So why should we expect patients to consider us trusted advisors on the most frightening and personal issues in their lives under the same conditions?  Without time to do the thorough workup required to come to an accurate and complete diagnosis and formulate a plan that works for the patient, with the pressure to crank through patient visits to get paid, and with patients understandably distrusting of their doctors under the circumstances, it’s no wonder that specialist referrals continue to rise.  We need fundamental change at the primary care level that empowers primary care providers to do the right thing as we are all trained and motivated to do.  Let’s not fight among ourselves, let’s look at the system and fix what’s truly wrong with it so that our patients and our country gets what we all need and deserve — high quality, reasonable cost health care.

  • Anonymous

    Good article. In my opinion, if we want to attack the outrageously high and ever skyrocketing costs of health care, we need less doctors and more Non-Physician Practitioners (NPP) in primary care. My guess? That’s where it’s all heading. The health care dollar can only be stretched so far. PCPs won’t admit it but they are gradually pricing themselves out of the market. With the advent of the ACO model, more primary care will be done by mid-levels. Folks need to get use to the idea that, in the future, the first professional that they encounter when they walk into an examination room will not necessarily be a doctor. 

  • http://profiles.google.com/mittmanpa David Mittman

    I am a PA who is not in primary care at this point in my life. 
    I think this has much to do with three factors. One is the lack of time many physicians have to deal with problems. There are many problems that get referred that good primary care physicians should be treating but do not have the time. If they take the time, they do not get reimbursed any more for that, so the better care you give-the less you make financially.  That is the second problem-simply you are not paid for your time, so why take up too much of it? Lastly, Kevin was correct in that the malpractice sword hangs over us all. Some people who have been burned cover their a**es by a referral.
    This post has nothing to do with NPs, PAs or physicians being better. I know all three professions that treat 90% of what’s wrong, and others that treat 25%.

    • Anonymous

      My PCP has entered into an agreement with a local hospital group to sell his practice and move his patient base into the hospital environment. He will become a salaried employee of the hospital. He will see the same patient base as before. The difference is that he will no longer have to worry about paying to run his own office, his own staff and pay for everything all by himself while he tries to devote time to his patients. In the new facility, he works regularly schedules hours, he’ll get regularly scheduled vacations, he’ll get a paid health plan and dental plan, he’ll have a choice of a pension plan or a 401k plan. With his new company, he’s not concerned about paying the electric bill, the heating bill, the phone bill, the internet bill, the rent, office painting and decorating and maintenance, the office staff, malpractice insurance, billing, none of that. All those things are handled by the company he works for. So, fully 100 percent of his time is dedicated for his patients. His patients will have a beautiful hospital for “all” of their needs. A cafeteria, a beautiful restaurant, and very large and beautiful lobby and waiting area, free parking, a gift shop and a pharmacy. For those who are smart, this is the future of health care. The days of getting your health care in the converted garage of a private home are coming to a close. 

    • Anonymous

      Dave you missed the point; you know all too well primary physicans tout that one of the danger s of independent NPs is too many referrals – so indirectly this article has everything to do with the issue. You know, clean your own house before you come and tell me how to clean mine.

  • http://www.facebook.com/people/Arnold-Wax/100000381145770 Arnold Wax

    The increased number of referrals to specialists, is due to either ignorance or apathy of primary care physicians in handling any type of semi-complex medical issue. If there is a single abnormality in any test, the result is an automatic specialty referral. It is this hematology/oncology physician’s long-standing opinion, that the evaluation of a hypochromic/microcytic anemia, is the purview of an internist or family practitioner. The differential diagnosis, is hardly vast, and the treatment is simple. However, all too frequently this picture results in a specialty referral. Just this week, I received a referral for a patient with a diagnosis of bruising. The patient was receiving aspirin. A simple question, results in the obvious diagnosis (Occam’s razor). Until doctors regain the time, and confidence, to think a problem through, they will be relegated to a role lower than a mid-level provider.

    • Anonymous

      “…due to either ignorance or apathy of primary care physicians in handling any type of semi-complex medical issue”
      Not so!If you talk to my PCP, it’s a simple matter of time. He says, in order to stay above water, he needs to herd patients through like cattle. The more time he spends with one patient, the less time the next patient gets. It isn’t rocket science. It’s about time and volume! He always says, “It’s nothing but expensive triage!”

    • Anonymous

      Jindal and S,

      Read the last line of this post – my point exactly. Hopefully this thread will help you see the disgust and didain people like Wax have for us (lower than a mid-level provider). Although it doesn’t matter – we will soon be the majority of their source of referrals.

  • Anonymous

    so do you think RNs should practice independently?

    how about LPNs?

    • Anonymous


      You answer that question. Are they educated to provide primary care? Do they have independent authority to diagnose and treat? Have they been expsoed to this type of education in their formal education? If yes, then yes; if no, then no. We both know the answer to that; you are obfuscating with your questions.

      • Anonymous

        i honestly don’t know if they’re educated as such.  same for NPs. what exactly is the difference?

        also “educated to provide primary care” depends on the definition of “primary care”.

        To me there is a huge difference between someone board-certified in internal medicine vs. family practice vs. pediatrics vs. ob/gyn vs. psychiatry.

    • liz mangieri

      If you ‘honestly don’t know’  the education of LPNs and RNs relative to NPs then the limits of your knowledge becomes very clear.  I would, in the interests of your practice and the fiscal health of your professional future, urgently ask that you learn the differences as they are vastly important.  I won’t attempt that education here, but if you employ an LPN or an RN you must understand what each can and cannot do given their licensure and as your employee.  I doubt you will ever employ an NP but suffice it to know that they’re huge assets to our bottom line and since we added the first one to our group eight years ago (three more NPs and two PAs since then), we’ve been thrilled with their success.  We did have to terminate one due to issues with manual dexterity (our midlevels do a lot of dermatologic surgery), but they can and do work alone with our full support and confidence.  It’s all about the professional mix as in any large group practice and of course, the senior partners practice paradigm.  Good Luck!

  • Anonymous

    My primary care doctor says that in order for him to get more affordable malpractice insurance, his malpractice insurance company encourages him to do less. It’s like auto insurance. If you drive less, you get a discount. It has nothing to do with qualifications or experience or willingness to perform tests and procedures or prescribing medicines. It has everything to do with reducing his out-of-pocket expenses. The more risk he takes on, the more he pays for insurance. 

  • http://www.facebook.com/people/Steven-Reznick/100000549195050 Steven Reznick

    I am not sure that insurance companies ask us to do less. They just charge more if you do in office surgery, or in office bariatrics or weight control or in office pain management. If the risk is higher  they charge more. I am not saying this to be supportive of a predatory insurance industry and trial lawyer industry but that is just the way it is. The other factor involves where you practice. If you are in a physician rich area it is more difficult to perform procedures with specialists in plentiful supply nearby. To give you an example. When my community had few dermatologists within driving distance in the 1970′s and early 1980′s most PCPs routinely did simple skin biopsies, lanced abscesses and simple lesions. With numerous dermatologists and plastic surgeons within walking distance you get to perform fewer of these procedures and there comes a point where you don’t perform the procedure frequently enough to justify your competence and skill compared to someone who does several every day. In training you look forward to performing arterial cutdowns, inserting CVP lines, doing bone marrow aspirations and biopsies, intubating a patient, putting in a temporary pacemaker. When you leave training and do these procedures infrequently based on your patients needs, why would you continue to do them when you can call in someone who does these procedures well every day. When I came to my private practice my initial employer had stress testing equipment in his office. There were few cardiologists nearby. In the same location I can close my eyes and throw a stone in any direction and reach a cardiology office. How can I justify stress testing when they have a higher level of training in this area and do more per week than I do.  If you practice in a rural area where you do not have the availability of specialty backup you continue to use more of l the skills you developed in training. Like anything else if you don’t use it you lose it. Most of the PCP’s I know have made a conscious decision to cut back on the procedures they perform less frequently out of concern for their patients safety and welfare since there is someone locally who has a higher skill level based on training and number of procedures performed.

  • Anonymous

    “…with more doctors exiting private practice and into salaried hospital positions, that reason will become less relevant…”

    I don’t think that statement holds water in all cases.  Our local hospital/cartel employs >97% of the primary care docs that are not university employed.  They also own a majority of specialty groups that they have aquired over the last few years.  Some of these under duress as they are (as am I) required to do the hospital’s bidding under the bylaws….and see and follow ALL patients that fall into the cartel’s web.  This has made it hard for some of these once private folks to stay in business.

    I was at the table of the executive council of my state medical society when one the the hospital owned primary care care guys was explaining to one of the council staff how it works.

    Nutshell, he said that whether the patient could pay or not they would provide care because of several reasons.  They were paid on an RVU productivity basis.  At the end of their fiscal year the RVUs were assigned a per RVU payment to doctor value.  They refer very extensively to their hospital owned specialists and test extensively to jack up the value of the RVUs….they see the uninsured because they are “non profit”.   So at the end of the year I make a pretty sweet bonus.

    I looked at him with a sour look and said that it sounded quid pro quo to me.  Sounds like Stark problems.  He smiled and said that it all gets laundered through the “non profit” hospital.

    Sounds like incentive enough to me for PMDs to refer….to their own “partners in crime.”

    Don’t think this will work in ACO capatation.  It will be interesting to see if any changes come from it.

    • http://pulse.yahoo.com/_2LRZNHDZS6DU45WQ567LPQ7CMI ninguem

      And if you don’t want to participate in the process anymore, they hit you with a noncompete (restrictive covenant), and you’re run out of the area.

      If you were a lawyer in a law firm, instead of a physician in a healthcare organization, such restrictive covenants would be null and void, by law. It would be the unethical practice of law to push such an arrangement on a new lawyer. The lawyers consider it unethical, among other reasons, it restricts the public’s ability to access lawyers.

      I’ve actually seen noncompetes enforced in small communities, where it really did create demonstrable difficulty finding a physician.

  • http://www.facebook.com/profile.php?id=684389833 Maryanne Doty

    I used to set up the referrals for our patients to see specialists, and it is a very interesting aspect to family practice.  My way of choosing which specialist varied, first, if the PCP (my boss) had a specific doctor in mind, of course I would start there, but more often I would get the chart with a note that the pt needs whatever specialist.  I first started with insurance, making sure the specialist accepted the pt’s isnurance, then worked with the pt to set up their consult.  I did develop relationships with some particular specialists, which improved our patient’s wait time to see the specialist, especially if they needed an ortho, and location was always an aspect as well as hospital preference.   When this was my job, the specialist was chosen with the patient’s needs in mind, but I have leanred that many times there are “hidden” agendas sadly

  • http://twitter.com/TheUnorthodoc Doc Cory

    “the tyranny of the 15 minute visit” hits the nail on the head. For primary care MDs, it becomes an issue of both energy management and resentment… I heard a colleague say this last year, 

    “If an endocrinologist is going to get paid twice as much as I will for managing the patient’s diabetes AND has access to educators, nutritionists, etc, why should I even try? The system only rewards me for churning through more patients, not managing them”I submit this for thought, without further comment

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