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.