Here, or There?: The Art of the Referral



Hand writing Referral Marketing with black marker on transparent wipe board.

Physician referrals play an integral part in care coordination. In the last several years, more and more newly insured patients have been flooding doctors’ offices in search of quality healthcare. In cases of complex and confounding diagnoses, or conditions that fall outside a practitioner’s wheelhouse, doctors must rely upon the expertise of the specialists practicing within their care network.

But what exactly constitutes a “complex” diagnosis? When exactly is it right to refer, and in whose best interest is it? Furthermore, does the term “network” mean simply a long list of specialists in the same MPN as you, or can you extend its meaning to include those you are well acquainted with professionally and maybe personally?

Getting to know your patient

It’s true that failure to refer a patient when necessary can lead to malpractice, or the potential endangerment or death of a patient. On the other hand, referring out a patient for an unnecessary procedure can yield the same results. While many caution one way or the other, one thing is certain: however they may strive for the highest level of professional competence, no PCP is perfect. In fact, understanding this is the first step to solving the referral dilemma.

Actor Hugh Laurie’s cynical, yet brilliant character Dr. Gregory House took on diagnoses the way a famous consulting detective took on crimes. He was methodical and clinical, though at times wildly unconventional. He cared chiefly about the disease, about the affliction, and had little time for the afflicted. He focused on what wasn’t functioning, how it should have been functioning, and what possible (and highly creative) variables could have been preventing this. For eight seasons, this made for great television…

…though it makes for horrible medical practice in the real world. The fact is, knowing a patient well is by far more valuable than knowing the disease. Now, by no means does intimately knowing a patient’s history negate the need to refer out. What we suggest is to first give each patient the time they deserve. The average physician spends about fifteen minutes with them in the examination room. What beyond very common illness or injury can be diagnosed in fifteen minutes? (Even Dr. House needed about forty-five, or so…)

No, we don’t expect forty-five minutes to become your new benchmark. But it is important to give a patient the time needed to speak, to be consciously present as they do, and to document as thoroughly as possible.

Putting a plan in place

So, your patient has returned for a follow-up appointment, complaining of the same issues as before. Sometimes it takes a few appointments for a condition to become clear. Symptoms can decrease, worsen, or stay the same, compounded sometimes by new ones that can confirm what you’ve been suspecting. A noticeable physical change in a patient may further support this as well.

Physicians and specialists often work deductively. With a mastery of the facts, they are able to rule things out. Of course, they don’t have all the time in the world for this end. A cut-off is necessary, and you should have your own in place. For example, if you haven’t figured out a patient’s problem within three visits, then it may be time to seek help, either from a colleague in your office or an outside referral. If you’ve done your due diligence with this patient over an appropriate period and documented it thoroughly, their record should clearly show that you were in the right for referring them out.

Networking within your network

PCPs provide preventive care and routine treatment. But if an issue related to the patient’s condition is outside their realm of expertise, it is almost required that they refer them out. Let’s go back to Dr. House one last time. Being employed at a teaching hospital, he had at his weekly disposal a diverse group of loyal colleagues and specialists. While he spent a lot of time pithily criticizing their diagnostic capabilities, they were nonetheless important to him, and he managed to keep them close despite his persistent anti-social behavior, melancholia, and cynicism.

While he goes out of his way to remind his peers and subordinates both of his brilliance and their inescapable shortcomings, Dr. House respected his colleagues. He knew each of them well, knew their strengths and weaknesses, and wouldn’t trust anyone else outside this circle for support. Let’s turn the discussion back to you. Which specialists do you most commonly refer patients to? Would you stake your reputation on theirs? Would they in turn do the same for you?

PCPs are only liable for the care they administer, and it is unlikely that a specialist within your network would be highly disreputable. Communication and mutual respect between PCPs and specialists can, however, be the difference between receiving a timely follow-up or not. In addition to the common avenues of networking, coordinating “Lunch & Learns”, or other events are a great way to build relationships with other clinicians in your MPN.

At such events, strive to be sociable, and gracious. Make sure that discussions are meaningful. What can your office do to help a colleague’s during the referral process, and vice versa? If you’ve successfully implemented a few outside-the-box solutions recently at your practice, then share them. Try to involve everyone in attendance, from the clinical staff to the billing team. Leave your card, and take theirs. Make sure you’ve made such an impression that yours will be among the names remembered, and for the right reasons.



Brian Torchin

| HCRC Staffing | |

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