Jennifer Larson

Employed physicians now outnumber self-employed physicians practicing in the United States, according to a 

 physician practice patterns from the American Medical Association. In fact, employed physicians now represent 47.4 percent of physicians providing patient care, compared with 45.9 percent of self-employed physicians.

The AMA points out that, for now, most physicians do still work in small practices. The percentage has been dropping since 2012, although 

the decline has slowed somewhat in the last few years

, according to research from the Physicians Advocacy Institute. 

In this evolving climate, it’s more important than ever for independent physicians to have strong referral networks. That means reaching out to other physicians, hospitals, long-term care facilities, and healthcare providers. 

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Independent physicians might not think they have enough time to spend on outreach to build those strong networks. Or they might assume they don’t need to spend time nurturing those relationships and networks that they’ve already built. 

But they need to make the time. And if they’re creative and persistent, it might not be as onerous as they might think. 

Nothing beats the personal touch when it comes to cultivating a referral network. Physicians who reach out to other physicians with a personal call, visit, or email will reap the benefits. 

Norman Wall, DO, a general medicine physician in Temecula, California, began building his referral network by picking up the phone. He’d call a physician and ask them to lunch so they could get to know each other. He concentrated on making a good impression on them and showing how the relationship could benefit both of them. 

“You have to build up that rapport with people,” he says. 

To continually strengthen her own referral network, Houston breast oncology surgeon 

, seeks out new gynecologists who’ve recently finished residency. She tells them about herself, her practice, and all the specialty services that she can offer to their patients. Then, when they need to refer a patient to a breast surgeon, they think of her and she becomes part of their referral network.

, a member of the National Society of Healthcare Business Consultants (NSCHBC), has a whole list of strategies that she recommends to independent practices who want to make personal connections. If you’re new in town or new to a practice, hold an open house and send invitations to other physicians. Join your local medical society or professional association and network at meetings or even at after-hours events with other physicians in person. Send gift baskets to other practices with a personalized note saying that you appreciate their referrals.

“And don’t forget all the people who keep the practice running. If you’re sending a ‘thank you’ gift basket to a referring physician, send a gift to the office staff too, says Phairas, president of Practice & Liability Consultants.”

Earlier this year, the Eye and Laser Center in Lancaster, SC, created a new position to streamline the back-and-forth of the referral process. 

If a patient exhibits the early signs of diabetic retinopathy, the doctors typically refer the patient back to their regular primary care provider or a primary care provider in the practice’s referral network for screening for diabetes. The provider relations coordinator follows up to make sure the primary care physician received the patient’s records and that the patient showed up for the follow-up visit. When a primary care physician needs to refer a patient to the Eye and Laser Center, they can easily reach the provider relations coordinator. 

“It’s a matter of working with the primary care provider together to close those referral loops,” says practice administrator Noah England. 

When you see a patient from a referring physician, be sure to follow up with them in a timely manner. It’s too easy to let patient information get lost in the shuffle, but that can be a source of frustration to that referring physician. 

How to achieve that: talk to your referral sources. Ask about their communication preferences. Ask how they’d like you to follow up with them. Do they prefer to receive faxes or phone calls after they’ve referred a patient to you? How much detail do they want you to provide? Honor those kinds of requests.

“Remember, those referring doctors are your customers, too, and you need to make them happy and feel comfortable referring patients to you,” says Phairas. 

Do you know who is referring patients to you and how often? How are you keeping track? Data can be a critical asset when it comes to understanding the sources of your referrals. 

“Accruing your data to understand your reference networks is really important,” says orthopedic surgeon 

, managing partner of the orthopedic group OrthoIllinois.

His practice collects data so it can track the referral sources for incoming patients. Twice each year, they analyze the data to notice patterns. When they find that certain sources have stopped sending over patients or find others who have boosted their numbers of referrals, they can and do follow up appropriately. 

The Eye and Laser Center also analyzes data from its electronic health record to gauge their referral patterns, England says. And when the practice notes a physician’s referrals have dropped off, the practice’s provider relations coordinator pays a visit in person to that provider. 

If you’re only thinking about physicians as sources of referrals, it may be time to think more broadly. 

“Diversify your referral sources,” says Van Thiel, who suggests including physical therapists, nutritionists, chiropractors and even alternative medicine practitioners in your network. 

“Don’t rule other potential sources that might not immediately spring to mind, like nonprofit organizations and community groups,” says physician practice consultant 

, president of Wellness Works Management Partners. “They may need to refer members or patients to physicians for very specific need, and you may fit that need-if they know about you.” 

“When developing referral networks, you want to find people who have that pain of finding the right fit,” he says. 

One more important thing to consider when building and maintaining your referral network: your patients. Patients who are satisfied with the care they receive can be an excellent referral source because they’ll spread the word.

“Most referral networks are built by word of mouth,” says Clive Fields, MD, a primary care physician in Houston and chief medical officer of VillageMD.

If you invest time and energy into building a robust referral network, why would you leave it alone to survive by itself? You need to continue nurturing it to help it flourish in the long run. 

Want your network to know more about what you do? Educate them and remind them that strong referral networks are a two-way street. For example, primary care physicians could reach out to their specialists and let them know more about the care they deliver. 

“Many specialists don’t understand the scope of services that a board-certified family medicine physician or internist can provide,” says Fields. 

Another suggestion from several experts: send thank-you notes to physicians when they refer a patient to you. In fact, Seigel suggested carving out even just two hours each month and make personal phone calls or send handwritten cards to your referral sources.

“That’s the personal touch that it takes to make an impact,” he says. 

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With time and creativity, the process is not as onerous as it may seem.

Building and maintaining a strong referral network 

As the opioid crisis continues, frontline caregivers need the most appropriate tools to combat the opioid crisis, including 

But do they have access to them? And are there enough of these frontline caregivers with the tools they need to help people suffering from an opioid addiction?

Medication-assisted treatment, or MAT, involves the use of certain medications, along with counseling and other behavioral therapies. 

 used in MAT, according to the Substance Abuse and Mental Health Services Administration (SAMHSA). 

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Currently, access to this kind of treatment is a challenge for patients across the country, says 

, associate professor and vice chair of community services in the Department of Family and Community Medicine at McGovern Medical School at The University of Texas Health Science Center at Houston (UTHealth) and the chief of staff of Ambulatory Care Services in the Harris Health System. 

In Houston, the methadone clinics can’t handle the volume of patients affected with an opioid use disorder.

Improving access to treatment and recovery services and promoting the use of overdose-reversing drugs are two of the U.S. Department of Health and Human Services’ five top priorities in responding to the ongoing opioid crisis, but clinicians can’t just prescribe 

 when they want to; physicians must obtain a special waiver certifying that they’ve completed relevant training. 

The federal Drug Addiction Treatment Act of 2000 (DATA 2000) requires that healthcare practitioners apply for a waiver in order to prescribe or dispense buprenorphine as a treatment for an opioid use disorder. First, physicians convey their 

 to the SAMHSA Center for Substance Abuse Treatment (CSAT). Currently, physician applicants must provide proof they’ve completed an eight-hour training course, plus their DEA number and their state medical license number, to be eligible to apply for a first-time waiver.

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Zare is the co-site principle investigator of a site in Houston that’s part of the national Primary care Opioid Disorders (PROUD) study, a clinical trial designed to examine which strategies can increase buprenorphine prescription rates in primary care settings. 

Zare’s team is testing out a collaborative care approach called the Massachusetts Model. They’re comparing one clinic with a clinical nurse manager to support three waiver-trained primary care providers against a control clinic without that additional support. They hope to find out if that support can expand the number of patients they’re able to see and treat in a primary-care setting. 

The goal is to find an approach that reaches more people who need MAT so they can experience long-term success. “They become more functional. They go back to work against. They start having a job and going back to their families,” says Zare.

Some suggest that the waiver requirement is a barrier to having more frontline clinicians prepared to provide MAT. But how much of a barrier is this requirement to get a waiver? 

The waiver does set limits to the number of patients to whom a provider can prescribe buprenorphine, but the training course is free and providers can complete it at their leisure, notes psychiatrist 

, program director of The Psychiatric Research Institute’s Center for Addiction Services and Treatment (CAST) at the University of Arkansas for Medical Sciences (UAMS).

“That is not a significant barrier,” he says. 

Nurse practitioners, PAs, and other advanced practice nurses can get waivers, too. They must complete 24 hours of training, or they can also take the same free eight-hour training that physicians take, plus an additional 16 hours of training from SAMHSA.

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In Arkansas, the number of providers with waivers has grown from 85 to more than 300 over the past few years, according to Mancino. But he says the waiver isn’t the biggest hurdle standing in the way of people gaining access to more waiver-trained clinicians.

“The number one barrier in Arkansas is stigma,” says Mancino. 

He explained that some clinicians don’t believe that addiction is an illness, thought it should be treated as such. Instead, some still view addiction to opioids (or other substances) as a moral failure or lack of willpower. 

Zare agrees that the mindset needs to shift. “Substance use disorder is a chronic disease,” he says. “We don’t stigmatize someone who has hypertension, we manage it chronically. We need to take patients with substance use disorder and treat them the same way.” 

examined the disparity between opioid overdose deaths and available treatment services in Flint, MI. The researchers found that opioid treatment centers were rarely located in the areas where the most overdose deaths occurred. 

That’s critical information because it shows where the greatest need lies and illustrates a geographical barrier for people who may want to access treatment but can’t, according to researcher and epidemiologist 

, associate dean for public health integration at Michigan State University and director of the Flint Center for Health Equity Solutions. 

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The study also illustrates the need for more healthcare professionals who are specialists in in addiction medicine, says Furr-Holden. A generalist with waiver training can be helpful, but having an adequate number of experts with the specialized training and experience is really critical. 

“Do you want an orthopedist delivering your baby?” Furr-Holden says. “You want somebody who’s trained. Treating addiction isn’t something that we can just make up as we go along.” 

“Our training and medical education needs to catch up to the problem,” she says. 

Frontline caregivers need the most appropriate tools, though access is a challenge.

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The winter holidays are upon us, and you may be on the receiving end of some holiday cheer from your patients. How do you handle that? Do you gratefully and gracefully accept gifts from your patients, or do you tactfully decline? Do you accept the gifts and then later pass the gifts along to someone else?

Reactions and choices can and do vary from physician to physician.

Christopher Drumm, MD, has already received pound cake, homemade pizzellas, wine, hot peppers and an ornament, and the season isn’t even over yet. But he accepted them somewhat reluctantly.

“Because accepting gifts does impact the doctor-patient dynamic,” says Drumm, a family practice physician with Norristown Family Physicians in Pennsylvania. He doesn’t want to feel pressured to order a test or prescribe a Zithromax Z-Pak for a viral infection, for example.
	Meanwhile, Gerard Hevern, MD, a family physician in Allenstown, New Hampshire, happily accepted the offer from a neighbor who’s also one of his patients to use his snowblower to clear his driveway after a recent storm dumped two feet of snow. He also accepts homemade treats and other gifts from his patients and thanks them warmly.

Here are a few things to consider when you’re wondering whether or not to accept gifts from patients:

Find out if your employer has an existing policy. 

The obvious place to start is with your employer (unless you’re the practice owner yourself). Your employer may have a specific policy that allows or discourages gifts. If not, you can always ask if they have any concerns or parameters if you’re in a position to receive a gift from a patient.

Check with your professional association.

 If you’re just not sure what to do, and you’d like to get some guidance from a third party, consider your professional association.  Some professional associations or organizations may have guidelines or recommendation that you can consult.
	For example, the American Medical Association includes an opinion section on Gifts from Patients in the association’s Code of Medical Ethics. This section does not specifically recommend that physicians accept or decline gifts, but it does advise them to consider a number of complex, interacting factors. The AMA’s policy notes that physicians should never allow a gift or offer of a gift to influence the medical care that they provide to those patients.

Consider how accepting (or refusing) a gift will affect your relationship. 

If a longtime patient brings you a container of homemade cookies or a bottle of wine, how will accepting that gift affect the relationship that you have forged with them? How would refusing that gift affect your relationship? Consider the possible ramifications that your actions could have. If you feel that your action could potentially hurt your relationship or make it awkward, let that guide you in your decision. If you do decide to decline the gift, take care to communicate your reasons for doing so.

 If you’re on your own about deciding, you could consider setting a price limit on the things that you’ll accept. The AMA’s Code of Medical Ethics suggests that physicians be sensitive to the value of a gift in context to both the patient and the physician’s means. “Physicians should decline gifts that are disproportionately large or inappropriately large, or when the physician would be uncomfortable to have colleagues know the gift had been accepted,” the section states.

For Drumm, the limit is $20. He calls it his “nothing over $20 rule.”

“I turned away a check and kindly have encouraged patients to keep the gift cards that they have brought in,” he says. “Anything very expensive or anything that is directly correlated to monetary value, I try not to accept.”

Be wary of gifts that are too personal, too. “Gifts for the office and staff are much more acceptable, but when patients make it too personal, you are opening the door up for trouble,” says Nicholas Jones, MD, a plastic surgeon in private practice in Atlanta.

 A gift can just mean that the patient is happy with their results, says Jones. It can just be their way of saying ‘thanks for doing a great job’ and that’s it.

Hevern suggests keeping it all in perspective. He doesn’t think it’s necessary to worry about receiving small items like a tin of brownies or a bottle of a wine from a patient. “The ethical things that I think we should be worried about are the big-ticket items,” says Hevern, naming issues like patients not getting access to the care they need or receiving denials for payment for medical care from their insurance companies.

There are ethical and legal considerations before accepting anything.

Author | Jennifer Larson

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