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You schmooze, you lose: How to win referrals and influence doctors

Specialists don't need a dog-and-pony show to land referrals. Primary care physicians just want them to be attentive -- and skilled.

By Mike Norbut, amednews staff. Feb. 3, 2003.

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Malcolm Deam, MD, has learned over the years that to land a boatload of referrals, specialists don't need to lure primary care doctors with slick brochures and glad-handing. While trolling the room may make a big splash initially, it's consistent availability and prompt attention that keep colleagues biting.

"I would rather provide quality service instead of trying to schmooze someone with candy or flowers," said Dr. Deam, an infectious disease specialist from Oak Park, Ill. "The most important thing is accessibility and promptness in communication."

Like in any business, gaining referrals depends a lot on relationships, but what some specialists are learning is that the relationship does not have to start with a free lunch. Save the fruit baskets, primary care doctors say, pay attention to details and stay in touch, and the relationship will probably grow.

"What I always tell doctors is the No. 1 way to gain or keep referrals is to have a high respect for the referring doctor," said Charles Wold, president of Wold Consulting in Phoenix. "You want to make sure you show appreciation, thanking him for having the confidence in you."

In other words, glitzy gimmicks are out, and old-fashioned responsiveness in. The letter template that specialists have that begins "It was my privilege to treat ..." could still be one of the best marketing tools.

The business of referrals, of course, is a subjective one, and it seems each doctor and consultant has theories about how to get them and observations on style vs. substance.

But one idea on which everyone seems to agree is that the most precious tool for a specialist is furthering his or her reputation by word of mouth.

This is probably good news for those specialists who don't like self-promotion.

"There's a lot of doctors who don't have the personality for it," said Barbara Reich, a health care marketing consultant in New York City. "To have to think in those terms, where they have to market themselves, they're totally mortified."

Fortunately for these doctors, many primary care physicians share a disdain for that kind of promotion.

Elliott Kroger, MD, an internist based in River Forest, Ill., says if a specialist depended on flashy marketing techniques as a way to earn referrals it "wouldn't be terribly persuasive, and might even be a negative."

"I tend to take it out of the realm of marketing," Dr. Kroger said. "I look for expertise. They have to be good at what they do."

Specialists also have to be accessible. If a primary care physician suggests that the patient visit a specific specialist, but that doctor doesn't have any openings for three or four weeks, it reflects poorly on the referring doctor. Conversely, if the patient returns to the primary care doctor with rave reviews of the specialist's care, it reinforces that the referring physician has good judgment.

"The patient will credit or blame me for the experience," Dr. Kroger said. "Maintaining their trust is predicated on making good choices for them. If they have a good experience, it's going to prompt me to send a second referral."

Primary care physicians have a lot riding on the referrals they make. The performance of the specialist reflects back on them.

And sometimes, a referral relationship can include a reverse referral. Popular specialists have been asked by a patient for the name of a good internist or family physician.

Rules of engagement

There are many practical reasons to take the more understated route in marketing, consultants said. In light of the Stark law ban on physician self-referrals and anti-kickback laws, physicians have to be careful how they pitch their services, lest the offers appear like payments for referrals. Even strategies such as an invitation for a meal or bringing lunch to the office could place the referring physician in a tight ethical box.

"I'd hate to view a [specialist] in the same light as a pharmaceutical rep," Dr. Kroger said. "Not to cast aspersions on the reps I'm friends with, but there should be a difference between them."

The law, however, looks at soliciting referrals in the much the same way as it views soliciting any business. And the same ethical restrictions apply.

For example, a new physician who hosts an open house needs to make it truly open, so it's not just a gathering of a few select doctors who eat free food and hear a sales pitch, said Gregory Hund, executive vice president of MD Resources Inc., a consulting firm in Fresno, Calif. "You have to be careful. You need to make it a general reception-type environment."

With many referrals dictated by managed care contracts and specialists in high demand virtually everywhere, there are plenty of chances to earn business just by being there.

But physicians new to an area or in a highly competitive specialty may find it difficult to convince primary care physicians set in their referral ways to change. Politics may be at play, but there also may be a comfort factor.

The trick is to get name recognition among colleagues without being too overt about it, said Theodore Hariton, MD, an ob-gyn from Tarzana, Calif. Face-to-face meetings with other doctors in the hospital cafeteria can make a positive impression, and hospital-sponsored lectures can help a specialist improve visibility and let primary care doctors learn about his or her area of expertise, Dr. Hariton said.

"When you take on a clinical topic within your field, it will make them aware of what you do," he advises other specialists.

Peer groups stick together

Dr. Hariton said he has observed over the years that doctors of the same age seem to gravitate toward one another, regardless of their specialty, so trying to land referrals from a doctor of a different generation may be a fruitless endeavor.

"You know they're socially going to be involved with specialists in their own age group," said Dr. Hariton, who has been in private practice for about 40 years. He said it's sometimes difficult to maintain a referral network now because a lot of the internists he knows are "retired, dead or dying."

Sieze the day

Specialists hoping to tap into a new referral source could see the first opportunity arise by chance.

If a primary care doctor's usual specialist is too busy to see a patient, for example, he or she may turn to a new specialist, possibly remembering one who made an impression with a lecture or made an interesting point during a lunchtime discussion.

"It's capitalism in the making at that point," Wold said. "If they see that little crack, they may try the other guy."

That, doctors say, is when the true marketing begins, and the campaign can be as simple as keeping the referring physician and the patient in the loop.

In an age where the means of communication are almost boundless, it's not unreasonable to expect prompt updates, primary care physicians said.

E-mail can even be an option, provided the specialist knows the referring physician is computer savvy and is sure the way the message sent is in compliance with the Health Insurance Portability and Accountability Act, consultants said.

Knowing the preferred method of communication is just another way a specialist can make a good impression, primary care doctors said.

A phone call, Dr. Kroger said, "is best," and a follow-up letter "is required."

Some specialists have other methods of getting their names on the minds of primary care doctors, such as handing out premade referral pads or tailoring a newsletter for other physicians.

But when it comes down to the bottom line, nothing compares with the basic principle of doing a good job, consultants said. And being easy to work with.

"I've heard some physicians say, 'So and so is fabulous, but he's miserable to deal with,' " Reich said.

"They want to do business with people they like."

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