MDs: How do you make referrals?

I’m in a county hospital system and I refer to people within our system. If it’s a service not provided by our hospital and clinics, I write a prior authorization to our health plan and they make a referral to a contracted provider. If it’s a particular clinical problem that I think that someone has a particular interest or skill I’ll refer directly to that person.

I also refer patients within the systems that I work in. In the VA, for example, if a vet needs a neurologist or an endocrinologist or any other specialty, I will contact the respective service and have them call the vet and schedule an appointment. Same with the county system in San Francisco. I refer folks within the hospital. If we don’t have a certain specialty, then I refer folks to the UCSF university hospital. I almost never work with and never refer people to physicians who are not university affiliated.

Our doctors have other doctors they prefer to send patients to because of the way they are able to work with that other doctor. First thing we do is ask the patient if they have a preference. We then discuss location and insurance coverage. Most of the patients that come into our office seem to know exactly who they want to see and our doctors will refer them to who they would like to see majority of the time.

So far it seems referrals have little to do with your knowledge of a doctors expertise?

@JLeslie Are you asking that question of me?

@Rarebear I guess it was more of a statement regarding all of the answers. Definently not aimed at anyone specifically. I had PM’ed Jeruba when she wrote the question, because I thought it was such an interesting one. I think patients like to think that our referring doctor actually knows the doctor they are referring us too, and feels confident in their skills as a physician, because they know them, or know of them through positive feedback. I have had two bad referrals recently, and my GP talked about having a relationship with that office before referring me, I realize now that has nothing to do with the doctors skills as a doctor or my specific needs.

I did, many years ago have a specialist of mine give me two very good referrals when we differed on our opinions of what I thought was at the root of some problems I was having. He gave me the name of a doctor he was friends with who he thought might agree with some of my ideas, and another doctor he had read about who had similar thinking. Those two doctors have been two of the biggest gifts to me. The referrals had nothing to do with insurance, money, or network.

Okay. Sometimes I personally know the person and sometimes I don’t. I have to have some trust as to a basic training. If someone is trained as an opthalmologist, I’m assuming that they know how to examine the eye. That said, if I get negative reports on someone, then I’ll try to avoid them in the future.

@Rarebear there have been a couple of specific times where I have seen many doctors for the same problem and am getting nowhere, needing someone who is specifically interested in my problem when not easily diagnosable. A doctor willing to think outside of the box, or who was very specialized training or specialized interests. An easy example, although not one of my problems, is a woman going through menopause seeking a GYN or endocrinologist who specifically focuses his/her practice on menopausal women.

For me one example was I needed a GYN or ID who was willing to give me a large dose of antibiotics, outside of what was standard medical practice, and when all cultures were coming back normal, and believe in it enough that I was not terrified I was doing something wrong that would cause me harm, be expensive, and/or be a waste of time.

Recently I decided to address muscle weakness and pain I have. I ignored it for years, mentioning it to doctors during regular appointments. I finally decided to go ahead and see a neurologist, that is that comment of my doctor having a relationship with that office, and I find out after the fact from my endocrinologist that the particular doctor I saw generally deals with children, and indeed there were many children in his office, many looked most likely disabled from birth. Seems there is a doc in that office who is more likely to see patients like me. That just pisses me off.

I want to add that I think my expectations were not realistic when it comes to referrals. Over time, and with the help of this thread that is even more apparent to me.

@JLeslie The thing about trying to refer patients to someone in network or covered by their insurace is to be as sure as you can that the patient will get the care they need. If we send a patient to a doctor that is not covered by their insurance, they aren’t likely to go back for follow up appointments when they need to because of the out of pocket expense.

@Seaofclouds Makes sense. I think it depends on the particular physical ailment, how specific the need is. The thing is, in-network I can go to the website and get a name also, I was hoping my doctor was giving me a name because he knows good things about that particular specialist.

This has been an eye-opener for me. When I make a professional referral, as far as I am concerned I am putting my reputation on the line. I am saying that I regard my colleague as a capable, reliable professional whose work I can vouch for.

I had hoped and believed that doctors put the same strength of conviction behind their referrals—that they were, in effect, saying “You can have as much confidence in them as you have in me.” If a referral is just a name on a list, what’s the point in asking?

@Jeruba The doctor’s in my office trust the people they refer too, but I really think that is all subjective. For example, my husband’s doctor spoke very highly about the ortho surgeon he referred my husband too. My husband trusted his doctor and ended up needing two knee surgeries (the first one and then one to correct where the doctor messed up). Sure, the surgeon could have had an off day, but once I started working at the hospital where the surgery was performed a month or so later, I learned very differently. Turns out that out of all the ortho surgeons in the area, my husban’s doctor referred him to the one with the worst reputation on the ortho unit. There were several other ortho surgeons that had a much better reputation. Now I wish my husband would have waited on his surgery until I had moved to Texas and started working so I would have had more information about the ortho surgeons in the area.

Most of the time, the only reason to really ask your doctor for a referral is because a lot of insurance companies require a referral from your primary doctor in order to see a specialist. Whenever I need to see a specialist, I always do my own research. Some of the best things you can learn about the doctors is to speak to nurses at the hospitals they have priveledges at. Those nurses often see several doctors in each specialty and really get a good idea of what those doctors are like and how they treat their patients.

@Seaofclouds the doctor who made the referral, I wonder if he spoke highly of the ortho guy because he knew of his work, by reputation, had actually gone to him as a patient, or just knew him on a personal level? I think what you have demonstrated is people outside of the medical system haven’t got a chance. If I give a referral, and have never done work with the person, I would state it, I would tell the person I know of him, but have never had business dealings with him before, because as @jeruba stated I feel some responsibility for the referral and level of service the person will be providing. I realize the doctor is probably just doing what is typical for the industry, and trying to be helpful, but we on the outside are clueless to what is really going on, our expectations are very different.

This has been eye opening. I wish I could give a bunch of GQ’s and I am so very appreciative to the doctors who were willing to answer.

I wonder what would happen, @Seaofclouds, if I walked into one of the hospitals hereabouts, tagged a nurse in the hallway, and asked, “Excuse me, but I was thinking of having knee surgery done here, and I just wondered what you think of Dr. Hatchet.” Or maybe, “Can you suggest a good knee surgeon? I need this operation, and I was hoping for a knowledgeable recommendation.”

I’m sure your comments are well founded. I just don’t know how I’d follow your advice as a layperson.

Just thinking out loud, I wonder if the whole HMO debacle changed the meaning of referral in the health field? During that time when HMO’s were so popular, primary care doctors became administrative assistants practically, pushing around the paper to move their patients to the needed specialty. I dont mean to diminish the care a primary gives, I am being critical of how the insurance companies work. Remnants of it still in play, because we still consider inside of the network or outside, rather than the best or most appropriate physician.

@Jeruba I have had people ask my opinion is of a certain doctor on many occasions. Usually they are in visiting someone else or they may even be my patient, but asking about a different doctor from the one they are seeing now. I try to give them my honest opinion based on what I’ve seen in the hospital.

I also like to go tour hospitals when I move to a new area and always chat with the nurses in the hospital when I’m there. I’ve never met a nurse that wasn’t willing to help me out.