Sunday, May 9, 2010

How Do Physicians Choose Consultants? Looking ‘Under the Radar’

Professional sports has never been a dominant personal interest, although I admit that I become more engaged if my town’s teams reach the post season. Here in Cleveland, folks assign a priority level to sports that is just a notch below breathing. I do make it a point to know enough of what is happening within the various stadiums and arenas so that I am not ostracized or placed in a stockade in the public square to serve as a deterrent. If the Cleveland Cavaliers do not emerge as national champions this year, then northeast Ohio will sink into the Sea of Melancholy

There is an aspect of professional sports that I greatly admire. This transcends the athleticism and skill of the athletes, the work ethic, coaching expertise, teamwork and the thrill of the game. This is one of the only institutions that is a pure meritocracy. The philosophy is simple and not blurred by arguments for diversity or massaging the qualifications for admission to serve another agenda. Coaches, managers and owners want the absolute best performing individuals for the job. And so do the players. I wish this ethos were contagious to the rest of us.

The practice of medicine is not a meritocracy, either in the manner that students are accepted into medical schools, or in how we physicians practice. For example, what criteria do physicians use when they select a consultant? The ideal response is self evident. A consultant should be chosen because that specialist is the best qualified and is readily available to serve the patient. Medicine, however, is not an ideal universe. Consultants are not routinely selected solely for clinical skill. In my experience, availablity trumps clinical acumen for many referring physicians who want their patients seen expeditiously.

These points apply to all physicians who consult colleagues, but primary care physicians are the primary source of specialty consultations.

Here are some reasons, beyond medical quality, why certain medical specialists are chosen.

• Reciprocity – patients are referred in both directions
• Personal relationships
• Corporate enforcement keeping consultations within the network
• Economic pressure exerted by consultants to maintain referrals.   I have seen this happen.
• Specialist willingness to do tests and procedures on request
• Habit
• Patient or family request

Even if a consultant is selected for some of the above reasons, the patient may still be ably served. For example, if a patient needs a screening colonoscopy, it does not matter that the gastroenterologist be a world class endoscopist. A simple community scoper, even one who blogs, may be sufficient.

In my experience, most patients receive high quality consultant care. However, patients are entitled to know that there may be unseen reasons why their physicians choose specific consultants. We specialists are not entirely righteous either. When we consult other physicians, we are also responding to forces that are under the radar. I personally admit to this in my practice.

When I entered private practice 10 years ago, after 10 years of a salaried position, I naively believed that conscientious care and availability would be a winning strategy to build my practice. I have learned that the dynamics between primary care and specialty physicians are more complex, and that the path to private practice success is not linear.

In sports, it's all about winning.  In medicine, it's also about how you play the game.

What’s your view?


  1. To me, the single most important thing about a consultant is communication. If I send a patient to a consultatant and they call me with their opinion after they see the patient with some reasonably intelligent opinions, they're my go to consultant.

    The same goes for radiologist. I don't need a call for every chest xray, but if I care enough about something to order a CT scan, I want to talk to the radiologist about it. In fact, I usually want to go over the films with them face to face, since this often leads to a better interpretation of the images than for the radiologist to look at them alone.

    I try to follow the same standard when I am the consultant. I call the referring doc the same day I see the patient, and put a letter in the mail that day. When I practiced in Hawaii I built up my consultant practice in less than 6 months this way.

  2. Nick, from your blog writing I already surmised your practice style in choosing consultants. In the larger medical arena, it's a different universe full of gray areas and blurry boundaries. While this isn't corrupt, it is invisible to patients.

  3. I think this is a great post. I'm glad KevinMD re-posted it, so I had the opportunity to come over here directly and let you know.

    It's such a murky area, this "consulting/referring" relationship. I'm all about transparency, so I have a soft spot in my heart for docs who like to shine light into dark areas.

    Lastly, I can't help but say I love the term "community scoper." That's a worthy blog title in and of itself. Maybe for your next act.

    As was said in Caddyshack: don't be so hard on yourself, judge, you're a REAL slouch.

    -Dr. John

  4. @Glass House, thanks for the kind words. I'm glad that you found the prestigious designation of community scoper to be so 'enlightening'!

  5. In my opinion, medicine is a cash flow business, predominantly. There are all kinds of excuses to keep me coming back for an office visit or for other testing.

    I had one doctor who insisted that I must come in for an office visit, just to get the results of lab work. She blocked all my attempts to get a copy from Quest Diagnostics, as they normally do. This doctor wanted money. I fired her, of course. I have many other examples.

  6. @anonymous, I certainly see your point and do not challenge you. On the other side, physicians often receive phone calls from patients who are attempting to have 'an office visit on the phone', perhaps,to save time or money. I'll handle simple questions on the phone, as I do every day, but I don't think it's fair to the patient or to me to be evaluating new or changing symptoms on the phone. In you own case where you state that the physician would not give lab work on the phone. What if your cholesterol or PSA were elevated? The discussions that these results would generate seem like office visit material to me.