Rules of attraction

Suzanne Al Houby likens the referral process to a turf war over patients. As CEO of the Dubai Bone & Joint Centre, she has seen first-hand the reluctance of primary care physicians (PCPs) to release their patients for specialist care.

After three years of practice, the facility has still yet to make a real indent into physician referrals. “Most of our patients, the majority are self referrals,” she admits, describing physician referrals as “a continuous challenge”.

“The whole community here historically does not like to work together.”

It’s no exaggeration to say that a solid referral base is a rare achievement in the Middle East. Specialist centres complain that extracting patients from first-line providers is a near-impossible task. “The whole dynamic is very different,” explains Dr Chris Canning, CEO of Moorfields Eye Hospital Dubai (MEHD).

It used to be that being available, amiable and accommodating was enough to guarantee a steady stream of patients. Now, heated competition means specialists must do more to make a mark with referrers. Medical Times has polled the experts to learn how best to corner a share of the market and convert one-time referrals into long-term supporters.

Formal flirtation

The route to increased referrals is equal parts courtship and confidence building, insists Dr Neil Baum, a New Orleans-based urologist and author of the book Marketing your Clinical Practice; Ethically, Effectively, Economically.

“PCPs want to hold on to their patients,” he says. “Specialists need to convince them that they are going to participate alongside them, and reassure them that they are going to get their patients back.”

The main strategy is to have your name cross the mind of the referring physician frequently, and with positive associations, a technique that requires less time in the practice and more time on the social circuit. Baum advises visiting each potential referral source personally to tell them about your area of expertise, taking along a copy of your CV.

“Think outside the box with the healthcare professionals you target,” Baum recommends. “There are multiple sources of referrals that are available, not just primary care practitioners. Podiatrists, dieticians, chiropractors – these people can all send you patients.”

Ward staff can also be a key source of referral. Position yourself as an expert in your field by offering seminars to nurses, or holding grand rounds at local hospitals. Cultivate these employees effectively, reports Baum, and you can secure a virtual sales team.

Moorfields has targeted local ophthalmologists by offering lectures covering the latest updates in their field. “It lets them know who we are, wrapped up in an educational programme,” Canning says. “These have been a good source of tertiary referrals.”

As an ambulatory facility, MEHD has also pooled resources with the American Hospital Dubai, to offer overnight beds to patients that require an inpatient stay. The quid pro quo, said Canning, is that the hospital refers on the patients it is unable to treat.

Baum has found some of his most lucrative referral sources in physicians he should outwardly be competing against. “You can get referrals from surgeons in your specialty, if you can offer skills they do not have,” he says. “It’s a value-added service for their patients.”

As important as raising your profile, is ensuring your availability. Practice consultant Susan Baker, author of Managing Patient Expectations; The Art of Finding and Keeping Loyal Patients, advocates establishing a direct dial number solely for use by referring physicians.

Answering that phone should be a top priority for everyone in the practice. “Make it easy for physicians to refer to you,” she says. “Provide cards with your contact information and a map to your practice.”

Small gestures can spark lucrative results, so Baker advises doctors to keep it personal. “Never ask another person to return referring physician’s phone calls. Place the call yourself.”

Handle with care

As important as securing referrals is knowing how to keep them. The fastest way to be struck off a physician’s referral list is by failing to observe good referral etiquette, and top of the list is communication.

When you receive patients, get diagnostic information back to the referral source speedily. A timely succinct report, says Baum, trumps a delayed, detailed one, and physicians give high marks for effective communication.

“There are three things that are important to a physician; diagnosis, medication and your treatment plan,” he says. “If you have a template, and you can enter those three things, you can get the report back to the referring physician’s office before the patient leaves yours.”

By keeping the doctor in the loop, Baum says, you’re deferring to their claim on the patient and building a reputation for efficiency. “The objective is to make that PCP feel that they are the captain of the patient’s healthcare ship,” he stresses.

Specialists should also be alert to the fact that primary care physicians are logistically unable to stay ahead of advances in every sub-specialty. If Baum is using a new technique on a patient, he sends educational material along with the referral note and flags up the text relevant to the treatment plan.

“If you can highlight the one or two sentences you want him or her to read, you’ll be educating the doctor and they will certainly appreciate it,” he insists.
Susan Baker ranks pleasing patients as one of the most effective means of keep referring physicians happy. As the ambassador between you and the referring physician, a patient’s verdict on your practice carries weight.

Patients will, naturally, tell their primary care physicians about their experiences with a specialist – and better primary care doctors will ask. One complaint isn’t likely to lose a specialist their referral source, but several will.

Baker proposes looking for opportunities to shore up the three-way relationship. She suggests speaking to referring physicians personally, to ferret out more information about the patient before his or her appointment.

“Then, when that patient comes in, you can say; ‘Dr Taraz and I were speaking about you, and he told me that…’ The patient feels reassured that both physicians are working as a team. Let the patient know something favourable about his or her physician too.”

It’s likely that early referrals will be the ‘difficult’ patients that physicians don’t relish treating themselves. School your staff to go above the bar with these patients, recommends Baker, and it will encourage physicians to send more business your way.

“Providing excellent care and service to those ‘difficult’ people and not complaining about them, will build the referring physician’s confidence in you,” she explains.

Patients are typically poorly equipped to judge clinical care, so will use bedside charm as a barometer for a physician’s skill. By being on time, considerate and differentiating your practice on service, you can maximise your chance of a favourable report.

Baker cites the example of a physician that supplies patients with a binder, holding their test results, a brief summary of the visit, and a reminder of any actions that require patient follow-through.

“He’s doing something that other physicians don’t do and it differentiates him,” she explains. “It saves staff time because patients – and their family members – have the information when they want it.”

When consultations result in a thank you note from a satisfied patient, Baum makes a point of sending a copy of the note to the referring doctor. “I am, after all, a reflection of his referral,” he says. “This lets him know he made a good decision when he chose my practice.”

Return to sender

The first rule of referrals is often the most overlooked – to hand the patient back. Horde a referred patient, and you can be sure it will be the last you receive from that physician.

“It’s easy to forget, but etiquette and decent common practice means that when you’ve treated the problem, the patient is returned to the physician,” Canning outlines.

And not clogging your appointment schedule with patients that could be better managed in primary care has added benefits. With a more flexible diary, specialists can maintain same-day scheduling policies that allow them to see urgent cases on the day or referral.

Patients with acute conditions will remember that they were seen promptly, and the courtesy will score points with their physician.

Baker suggests checking in regularly with referring doctors to see whether you can smooth the process to suit their preferences. “When you ask after the first patient, you may hear ‘Oh, everything was fine,” she explains.

“When you ask after subsequent patients, you may get some very helpful advice for keeping a smooth running relationship going forward.”

Returning patients, reminds Baum, should always be accompanied by a ‘thank you’ for the referral. A handwritten note expressing gratitude for the vote of confidence is a quick way to get your name across the physician’s desk in a favourable way.

“It cuts across all kinds of medical care – there are the two most important words in any culture,” Baum insists.

The question of also sending gifts in appreciation for referrals tends to divide physicians into two camps. Whether you think it appropriate or unethical, Baum reports, don’t expect it to win over doctors.

“I have never found a physician who says, Í’m sending a referral because he gave me a wine and cheese basket at holiday time,” he says, dryly.

If you do plan to send gifts, use them as another opportunity to keep your name in front of physicians. One year, Baum bought customised luggage tags for all his physicians.

“Every time their luggage arrived on the carousel, they were thinking of me,” he explains. Find similar excuses to keep referral sources updated on any new techniques or medications in your speciality. It could open up a new supply of patients but, at the very least, it will flag up your name again. “There’s an art to it,” Baum admits.

Making and maintaining referral relationships requires a mix of professional expertise, social skill and bedside charm. For specialists, no referrals means no business, so these are strategies worth investing in.

As Baum puts it; “If you can get a reputation of being a solid referral source, of returning the patient, and of providing outstanding service and care, you’re really going to see your practice grow.”