There’s been a recent shift in the balance of power when it comes to referral relationships, and practices are making efforts to adapt
It used to be that a specialist could hang out a shingle, pop into the local practices to meet the area’s general practitioners, and sit back and wait for patients to fill the waiting room.
But times are changing when it comes to referral relationships in Australia.
As there have always been, there are still letters of varying verbosity, phone calls, lots of trust, and potentially plenty of practice profit. Social and professional networks can play a role, as can personalities, prices and reputations.
But in an increasingly competitive specialist environment, professional marketers and doctor-to-doctor hotlines are also beginning to be part of the referral picture.
GPs in metropolitan areas with high numbers of specialists are now finding themselves the targets of polished campaigns encouraging them to change their referral patterns.
Inner Sydney GP Dr James Best says there have been commercial factors coming into play in referral relationships in recent years, particularly when it comes to the larger specialty group practices.
“Often these organisations have a lot of money and they employ marketing companies, and you can tell. All of a sudden there is a snazzily presented evening event and that sort of thing”, Dr Best says.
He says it’s also beginning to affect how new specialists introduce themselves.
“There are lots of young specialists now, to the point that marketing is also coming into play. We’re getting letters, requests to come and meet us, and that sort of thing from freshly graduated physicians and surgeons. That wasn’t happening 5 or 10 years ago.”
Dr Best attributes the shift to the weight of numbers — more specialists in city areas but not a relative increase in public positions so a greater need to foster private practice.
Caroline Ucherek is general manager of specialist medical marketer CJU, and says they are receiving more and more requests for assistance with establishing and maintaining referral relationships.
“Five years ago it was unheard of for marketing groups to be involved in the introduction of new specialists to the local GP community. Today it is becoming unexceptional”, she says.
“The new specialists who are coming out recognise that it’s something that needs to be done.”
CJU assists specialists to meet GPs in the local community and to provide what she describes as the intangibles referrers demand.
“What we’ve found is that the whole relationship between specialists and GPs has changed. Referrers expect more from specialists. They expect them to be much more accessible than they once were.
“GPs now are so much more overladen that when they’re looking for specialists, they’re seeking those intangible aspects of services. Apart from the fact that they must be technically proficient and clinically excellent, they want to have the intangible aspects of the service — the accessibility and the relationship where they can call if they need to for help in the management of the patient.”
Regardless of new bells and whistles, the basis of the referral relationship continues to be trust and communication for the welfare of the patient.
The University of New South Wales Centre for Primary Health Care and Equity recently completed research into referral relationships related to the treatment of diabetes and found they were influenced by both personal and professional rationale.
Leader of the research, Dr Julie McDonald, says that for GPs, interprofessional trust is central.
“GPs trust the specialists’ expertise and that they’re not going to take over the care of their patients so that the GPs never see them again”, she says.
Good referral relationships also help doctors manage their perceived risk. If they are uncertain about a patient, or a patient has a particularly complex condition, it’s important to know that there is someone to call for advice.
GP Dr Michael Tam agrees. He says that the referee being contactable by phone for a quick check or advice can also make the difference between an ongoing referral relationship and one that perhaps doesn’t extend beyond the first referral.
“Direct communication I think is very important”, Dr Tam says.
The value placed on this direct communication has seen the recent establishment of doctor-to-doctor hotlines between some specialist groups and their referring GPs.
A phone number is set up for GPs to ring, and one member of the specialist group is always on duty to answer the calls. The number is then printed on literature sent to doctors and is posted online.
For cardiologists in particular, such a hotline service is regarded as making the difference in a competitive market for those looking to increase their referrals.
Neurosurgeon Dr Mitchell Hansen says such pressure is a long way off in his field, but he has no problem taking calls from GPs himself.
“A short phone call can make it a lot easier to manage stuff. If you take the phone call, they [the GP] can normally do a lot of the legwork and you don’t have to”, Dr Hansen says.
Dr Hansen established his practice in Newcastle, north of Sydney, in July 2012.
He stepped into a public position at John Hunter Hospital which provided an immediate swag of referrals, but more recently he set up monthly one-day clinics in Port Macquarie on the mid north coast and Tamworth on the New England Tablelands and took steps to introduce himself to the local medical community.
“I letter-bombed everybody in the general practices in the Port Macquarie area and the Tamworth area”, he says.
He also invited the local GPs to an information night regarding spinal implants.
“I talked about how I manage spine referrals, which make up the bulk of what I get to see in the practice. I tried to put my face out a little bit.”
Dr Hansen’s spinal implant event also served to overcome an issue specialists have with some referral relationships — too little information and too little investigation before the referral is made.
“You don’t like being the person that is just dumped on — and with specialists that happens quite regularly unfortunately”, Dr Hansen says.
Receiving referrals where there is not enough information can be frustrating and can disadvantage patients.
“We are triaging things and you get letters asking ‘Can you see this patient sooner?’. A little more detail in a referral letter is important when it comes to triaging patients.
“‘Thanks for managing their back pain’ is not enough.”
Conversely, after a patient has been seen by a specialist, GPs generally prefer succinct and informative letters in return. Verbosity is verboten.
Ultimately, the patients’ opinions are central to any ongoing referrals, says Dr Best. With that in mind, he describes referral relationships as triangular — between the GP, the specialist and the patient.
For some patients, personality is very important; for others it’s cost.
Whatever the priority is, the doctors are trying to make a match.
Having different options available helps and at Dr Best’s practice, Your Doctors, they keep a list of all the specialists that the practice’s doctors refer to regularly.
As a subset of that list there is a group of preferred doctors and allied health practitioners for referrals.
These lists are kept online and are accessible to all the practice doctors so that further comments can be added when needed, such as the strengths of particular doctors or the procedures they can and can’t do.
“All the doctors and nurses can contribute to the body of knowledge that’s kept on the contacts list in our software.”
And Dr Best says that when a referral relationship is good it can be very, very good.
He has been referring people to some specialists for 17 years and estimates that he’s sent more than 300 patients to some of his colleagues’ waiting rooms during that time.
His only regret is that despite this extended period of professional cooperation and communication there are some that he has not yet got around to meeting.
“It’s a bit of a thorn in my side. There are some people that I’ve sent hundreds of patients to and I’ve never actually met them. We’re all just so busy.”