Tips for building a referral network

Personal connections drive many referrals between primary and specialty care physicians, but building relationships may feel daunting for early career physicians working in large systems. Effective use of online resources and good old-fashioned networking can help sustain productive partnerships that drive better patient outcomes.

“Taking care of patients for other physicians and sending them good information matters,” said Fred Pelzman, MD, medical director of Weill Cornell Internal Medicine Associates in New York, N.Y. “It's how you establish a reputation as a physician and build credibility with subspecialists, who will remember you when their patients need a good internist.”

Trust can develop even if physicians never meet in person, he said. For example, physicians who take time to leave detailed chart notes or exchange messages prior to consultations are more likely to maintain ongoing referral relationships.

Research suggests that establishing go-to partners and referral pathways has a significant impact on quality of care, as many patients rely on their primary care physicians for guidance. In a meta-analysis of seven studies, published in the April 19, 2022, Journal of General Internal Medicine, about a third of patients said they rely exclusively on their primary care clinician's suggestion when selecting a surgeon, and it was often the only factor for urban patients, patients of color, and those with limited Internet access.

Electronic systems that enable physicians to easily find and communicate with a wide range of specialists are critical to improving the referral process, said Alicia Arbaje, MD, PhD, MPH, FACP, a geriatrician and director of transitional care research at Johns Hopkins Medicine in Baltimore. But, she said, the best connections often start in person.

“Once a month or so, have lunch with someone or do one thing that allows you to meet someone new,” she said. “Getting out of our own sphere is always time well spent.”

Getting started

Experienced physicians highly value trust and personal relationships when making referrals, according to the JGIM review. Although clinical and technical skills were cited as important factors, physicians in the included studies mostly made those assessments based on personal knowledge or reputation rather than objective data.

Unfortunately, medical school and residency training offer little guidance about how to start building a network, the authors note. Physicians learn how to initiate consultations or communicate with specialists but not how to find those specialists and select the best options for individual patients.

Part of the solution is to supply all physicians with objective data on performance metrics or patient outcomes for the specialists in their network or region, the authors suggest. Doing so might help reduce disparities in referral practices and patient outcomes based on whether a patient's physician is in a remote or urban area, or affiliated with a small or large health system.

However, there are many ways to start forging connections in the absence of that objective framework, experienced physicians said.

For example, those who work in the same system where they completed training have a foundation to build upon, said Stephanie Nothelle, MD, who is a geriatrician at Johns Hopkins Bayview Medical Center in Baltimore, where she completed residency.

“My mentors are now colleagues, and some physicians I trained with have gone on to be specialists in different areas within the system,” she said. “I can ask them for recommendations of specific specialists, and they will often send an email to facilitate an introduction.”

If you're starting out in a new, unfamiliar system, seek out colleagues with institutional knowledge, advised Dr. Pelzman. “Who you know makes a huge difference. After 25 to 30 years, I know who the good specialists are for various issues and can pass that knowledge on to younger physicians.”

Make sure to connect with specialists whom mentors or colleagues recommend, he added. Most senior physicians appreciate the difficulty of getting started and are happy to help.

Events and meetings are another good way to connect with physicians outside your specialty area, he said. For instance, Weill Cornell has a weekly lecture series where subspecialists and surgeons are invited to talk about what they do.

“It's a great mechanism for cultivating those relationships that used to happen when we all hung out in the faculty lounge or bumped into each other in the elevator and asked for advice,” he said. “That's missing when we stay in our offices typing away on our computers.”

Similarly, introductions at meetings of ACP's Council of Subspecialty Societies—representing 24 internal medicine subspecialties—include an overview of each member's area of expertise and key clinical issues or areas of concern, said Dr. Arbaje, the current Chair of the Council.

“Many of us don't really know what different subspecialists do,” she said. “Having everyone in one room allows us to get to know each other.”

Events that span different specialties also facilitate connections with specialty care colleagues who are working on similar clinical issues, said Dr. Arbaje. For example, she said, she learned more about managing dementia in her geriatric practice through discussions with neurologists and psychiatrists she met at meetings.

Cultivating relationships

Of course, making a connection is just the beginning of building a network. Ongoing communication and collaboration are necessary to cultivate and maintain those ties.

Timely, productive communication is one of four guiding principles underlying effective collaborations between primary and specialty care, according to the 2022 ACP position paper “Beyond the Referral: Principles of Effective, Ongoing Primary and Specialty Care Collaboration.”

Communication should be focused, providing the right amount of information at the right time, the authors state. They also emphasize the importance of effective data sharing, where physicians exchange information that is essential to evaluating the patient and following up on recommendations.

“It's frustrating for patients to wait months for a specialty appointment only to find out that the specialist needs certain test results to take the next step,” said Ateev Mehrotra, MD, MPH, professor of health policy and medicine at Harvard Medical School in Boston. “With better communication between physicians in advance, those tests can be done before the appointment, potentially saving the patient an extra visit.”

On the primary care side, physicians should be clear about why they are requesting a consult, he said. A good referral request should include a brief summary of the patient's history, relevant test results, and a specific question that they'd like the specialist to answer.

“Patients often rely on their primary care physician to convey the issue to the specialist,” he said. “If the specialist doesn't have that information and the patient isn't able to explain, the visit ends up wasting time and possibly answering the wrong questions.”

Similarly, the specialist should follow up with specific recommendations for ongoing care, he added. The response should summarize the specialist's thinking on the problem and make very specific recommendations, such as naming medications and exact dosages.

Primary care physicians should also define what role they would like the specialist to take in the patient's care, according to the policy paper. Do they need advice or input on a clinical question or next step? Or would they like the specialist to comanage or take the lead in care?

Paving the way for a productive specialty visit sometimes takes extra work, noted Dr. Nothelle. Despite the primary care physician's best efforts, information on the referral request—which may be made months in advance of an appointment—may not be seen by the specialist.

“If I have a specific question or unique thing about a patient, I tell the patient and family to send me a message after they make the consult appointment,” she said. “I then send that specialist a message in advance to make sure they know about my specific issue or question. It's an extra step for me, but it can enhance communication and prevent a wasted visit.”

E-consults can ease the way

Many health systems use electronic referral systems to help physicians find and work effectively with specialists. Research suggests that the systems can help reduce backlogs for specialty appointments and more quickly connect patients with the appropriate level of care.

A Canadian study, published in the Dec. 14, 2021, CMAJ Open, reported that 48% to 76% of potential referrals were avoided after participating teams started using two e-consult platforms. Having access to remote consultations eliminated the need for a referral, in many cases, or avoided sending patients to the ED to get faster care.

Ontario now has two provincial e-consult platforms with access to 130 different types of specialists, said the study's senior investigator Erin Keely, MD, executive director and specialist lead for the Ontario eConsult Centre of Excellence. In most cases, referrals are avoided because the primary care physician can get advice or guidance that allows them to continue managing the patient, which, in turn, reduces the specialty care backlog.

“In over half of cases, it changed what physicians were going to do for that patient, such as change medications,” she said. “For others, it supported what they were already doing, such as starting or stopping a medication.”

That ability to check in with a specialist in a timely way is especially valuable for newer physicians, she said. It offers reassurance that they're on the right track and doing what's best for that patient.

In another study, New York City Health + Hospitals, a large safety-net health system, was able to reduce the average wait times for specialty appointments by 13% a year after implementing an e-consult system. The authors noted that physicians frequently used the system to resolve minor concerns or questions, thus freeing up more specialty appointments for patients with more urgent needs.

Having access to e-consults improves continuity and efficiency of care, said Dr. Mehrotra, a coauthor on the study, published in the May 21, 2021, JAMA Health Forum.

“In the past, I would give a patient a paper note and ask the front desk to make an appointment, which may be six to nine months out,” he said. “With e-consults I can connect with a specialty reviewer within 24 hours and find out if an appointment is necessary or what tests should be done in advance so the specialist has results when the patient arrives.”

Additionally, e-consult systems make it much easier for new physicians to find specialists who focus on very specific issues within large specialty areas, said Dr. Mehrotra.

“Having relationships with specific specialists that you trust is more difficult in the modern era,” he said. “Twenty years ago, I might have had a go-to cardiologist, but now we have enormous systems with hundreds of cardiologists with many different areas of expertise.”