Thursday, December 6, 2007

Referrals

When I was a resident, all I had to do was show up at work everyday and patients would magically materialize on my list. Usually, it was annoying because longer lists meant more work. The OR schedule was usually full as we covered cases of multiple attendings. As a chief resident, it's fun; you round in the morning and then operate all day. It never really crossed my mind to think about where all these patients came from. They don't arise out of a vacuum. Someone had to be referring them to our surgeons.

General surgeons depend on primary care doctors and internists for business. We don't post ads in the newspaper or phone book. You won't see me on television touting my laparoscopic skills or announcing a year end close out on hernia repairs. The system is set up such that a patient must go through his/her PCP gatekeeper to get in contact with a surgeon. Ideally, this means that a referring doctor, using wisdom and experience, will refer a patient to the surgeon he/she trusts. And sometimes that's exactly what happens. An internist will develop a relationship and a level of trust with a specific surgeon and will refer most patients his way. But in this era of managed care and large multispecialty groups, the ideal isn't always realized. A lot of internists don't have a choice which surgeon to refer to. You simply give the patient the phone number of the surgeon in the group or the one part of the correct insurance plan, irrespective of said surgeon's capability or performance. I work in a small group that is completely independent of the two major medical behemoths in the Cleveland area so I get shut out of the patient base that is underneath those umbrellas. Every once in a while I'll take care of a patient from the Cleveland Clinic system who comes in late through the ER and I'll take out the appendix or whatever and follow up with the primary care doc over the phone, but no matter how well the patient does, or how quickly he recovers, I won't see any more patients in the future from that primary care doc because I'm simply not part of his "system". And that can be frustrating for a young general surgeon building a practice. Referral patterns, in an ideal world, would be based on surgical excellence, clinical outcomes, and personal relationships. Unfortunately, the reality is far from that. There is no absolute meritocracy in American medicine anymore. Most people's insurance plans restrict access to certain physicians. At some point, it may be necessary to join the giant group paradigm just like everyone else.

5 comments:

rlbates said...

That it seems to me has just gotten more difficult over the years. Here we don't have the manditory hospital staff meetings anymore, so I find I don't know nearly as many of the other doctors, especially the newly graduated or new to the community. I, always, (half jokingly) said that I didn't play golf with the right general surgeons (never did establish the breast reconstr. referral base I thought would come). The gyns have been good with breast reduction referrals, but often because the patient asked for a woman. It is tough,....

Jeffrey said...

im sorry i dont really understand entirely, are you referring to public vs private practice.

i get this idea that in the public service, e.g. in a major tertiary hospital u get the referrals straight from the internists and ED right off. and perhaps some primary care physicians from the nearby community. i thought it was more a geographical thing.. of cos thats assuming all board certified surgeons have a baseline level of competence.

Buckeye Surgeon said...

Jeffrey-
This is strictly a suburban, private practice setting. The large tertiary referral centers and public/charity hospitals function much differently. In private practice youre competing for patients, whereas in public practice you're providing a service for the needy. The financial rewards for the former are much greater, but the professional satisfaction, so far ,seems higher in the latter.

Anonymous said...

they will come. it just takes time. the primary care docs were referring patients to someone before you got there. every patient you get referred would have gone to someone else if you had not been there. someone with a longer standing relationship with the primary who probably is worried that you are taking their business.

Anonymous said...

I would think in Cleveland it would be especially hard getting referrals while competing with CCF. I live in Lima and I have been referred to surgeons at CCF multiple times by our local doc's. Cleveland and Lima are not in close distance. It is about 3.5 hrs for me to drive to CCF and I knew no doc's there when I was first referred there. I could have just as easily been referred to you and I would have been seeing you instead of them. It is also referral on top of referral on top of referral. I initially had an appointment with the section head of thoracic surgery (Dr. T.R.) then it was off to a gastro specialist for a slew of tests, and then down to coronary for clearance from them which led to repeat visits and doubutamine stress tests, and then back up to rheumatology for yet more tests. A few stops at the lab and x-ray, on the way up or down and this made for alot of visits and alot of doctors to perform one surgery.