Building and Maintaining a Referral Base

Tips for newly graduated fellows.

By Murtaza Adam, MD

A steady stream of new patients sustains the lifeblood of a successful retina practice.


• Even if you join a practice with an existing network of referring doctors, the practice will still need to be grown over time and nothing beats in-person introductions to accomplish this goal.

• Know in advance whether the practice you are joining is willing to share patients and referral sources or expects you to work for your own.

• The most important part of establishing and maintaining business relationships with referring doctors is to communicate well and take great care of their patients.

Those in vitreoretinal surgery training programs reap the benefits of joining well-established institutions under the tutelage of retina surgeons who are in the prime of their careers. The flow of new referrals in this setting seems to never end. However, for new graduates starting in their first (and hopefully last) practice, building patient volume can take significant time and persistence. Culturing relationships with referring doctors and establishing a reputation does not happen over night. Allen Chiang, MD, and James Vander, MD, break down the basics of creating and maintaining a referral base.

What are the key components to building a referral base?

Allen Chiang, MD: Most employment opportunities will have an existing network of referring doctors; however, this will still need to be grown over time. Other practice opportunities may be entirely new ventures that will require you to build a brand new referral base. In both situations, but especially in the latter, there is no substitute to pounding the pavement, meeting as many potential referring doctors and groups as possible. Doing this the old fashioned way with a firm handshake, a smile, and conversing face to face can leave a lasting first impression that says that you value the referring doctor. This is a simple and worthwhile practice you can begin doing even before your official start date.

As an aside, I believe there is a generational aspect to relationships with referring providers. You will often see a high yield if you start by seeking out the referring providers who are your peers. Naturally you will have more in common with them than you will some of the more seasoned surgeons, and often these individuals become enduring referral sources. Sometimes I end up talking more about the challenges of trying to balance practice and rear young children with my group of referring provider peers than about patients, and that is part of what makes these relationships take off.

James Vander, MD: The three “A’s” of referral development are: availability, affability, and ability—in descending order of importance. It helps enormously to be able. You might be God’s gift to retina surgery, but if you do not have availability and affability, you will not succeed. First impressions for a new referral are extremely important. If a new patient returns to his or her primary ophthalmologist complaining about you or your staff, consider that referral source lost. You also have to be ready and willing to help when needed. This relates to the insurance plans that you accept, your physical proximity to a referral source and their patients, and the office hours you keep.

How does one maintain a referral base? How often should referral sources be contacted?

Dr. Chiang: The answer may depend in part on the market and on the particular doctor or group of doctors that you are servicing. For instance, in highly saturated and competitive regions, it may take several attempts to win over a referring doctor and establish a fruitful relationship. Thereafter, as with any business relationship, it is important to keep the lines of communication open. In general, I have found it helpful to engage in personal contact at least once or twice a year. This may occur in social settings, such as at a regional ophthalmological society dinner meeting. In between, you can recruit a member of your staff to serve as a liaison to check in on referring doctors every few months, which saves time and provides invaluable feedback. You may find out, for example, that the referring doctor wants more frequent letter updates on his or her patients. Otherwise, you will interact most frequently via phone or text about patients, particularly those referred to you with severe or unusual pathology.

Dr. Vander: That question is not as simple as it sounds. It depends a lot on the personality of the referring doctor. Some doctors simply want to know that they can trust you and that you will be available to provide great care for their patients in a timely manner. Some sit by their electronic mailbox waiting for a letter to know how their patients are doing. Others prefer a phone call. I would emphasize that if there is a patient that the referring doctor might be especially nervous about, such as someone with a dropped lens or a postcataract retinal detachment or endophthalmitis, then you cannot reach out too often. Sending a simple text message with a patient update can make a big difference.

How does one avoid competing with partners within a practice?

Dr. Chiang: One way in which large groups remain cohesive is by delivering consistent, high-quality service. We vet and hire surgeons of the same high caliber with regard to skill, character, and judgment. This instills confidence in referring providers to trust any of the partners in the practice.

Dr. Vander: It is a matter of practice philosophy. One should flush that out before signing a new contract. Some practices will open a new office 30 miles from their busiest established clinic and will expect a new associate to build patient volume for the new office without poaching established referral sources. You need to know in advance what kind of practice you are joining. In general, if established partners make more revenue with increased patient volume seen by a new associate, the practice is much more likely to provide a higher base salary and share patients and referral sources. When signing an “eat what you kill” contract with lower base salary but better reimbursement for high productivity, the practice generally expects you to work for your referral sources.

What, if any, differences are there for small practices versus large practices?

Dr. Chiang: Whether large or small, a practice must have a fair and reasonable internal system of distributing referrals in order to function well. As far as referral sources go, they will usually presume that your partners selected you to join their practice for good reason. However, it is up to you to confirm this presumption.

Dr. Vander: If you are joining a large, well-established practice in a community, the referring doctors to that practice likely expect that any new associates are cut from the same cloth as the other doctors in the practice. This certainly makes referring doctors more amenable to sending patients to a new associate. You will also probably find that the doctors within your own practice are much more comfortable with the idea of sharing referral sources.

In smaller practices, there tends to be a bit more “ownership” of referral sources and you may come across attitudes of “Dr. Smith is my referring doctor and Dr. Jones is yours.” A big question for new associates in smaller practices relates to the practice’s philosophy on sharing referral sources. Practices that are comfortable with sharing referrals will typically encourage it and convey this policy to their referring doctors. In practices not amenable to sharing referral sources between providers, there will be a much greater challenge to obtaining new referrals.

How important are things such as educational dinners or tickets to games and shows?

Dr. Chiang: Particularly in the first 2 years of practice, be prepared to do any of the above in order to establish and maintain the business relationship. A good rule of thumb is to simply inquire as to what the referring provider prefers. In most cases I believe it is a matter of quality over quantity. Most people are busy and will prefer a quick meeting of some kind, while some may enjoy a dinner lecture or an outing to a ballgame. Regardless, the most important thing is to communicate well and take great care of their patients.

Dr. Vander: In general, these things are not too important. If we are talking about most practices, where there are already existing referral sources, then these doctors probably just want you to come by and say hello. They want to make sure you do not have horns or three heads. On the other hand, if you are expected to go in to a new community to generate new referrals, then these things matter a lot more. As an opportunity to entice someone to spend a few hours with you, it is helpful to have an excuse. Referring doctors may not be interested in a show or a game, but you might bring lunch to their office to say hello or take them out for a drink or quick dinner after work.

When one assumes someone else’s patient volume (ie, is hired in a practice to take over for someone who is retiring), how important is it to reach out to referring providers for the retiring doctor? Should there be a formal transition?

Dr. Chiang: I think it is critical to reach out to the referring providers in order to keep referrals coming. Your goal should be to exceed their expectations. To do that, though, you need to know what those expectations are, so do not make assumptions! You will identify the specific behaviors the retiring doctor did that kept them happy, and may also uncover a few things that they did not do as well—things to avoid repeating. If possible, it can be helpful to have a conversation with the retiring doctor specifically to pick his or her mind about various referral sources.

Dr. Vander: Most practices do not have referring doctors who only refer to one partner within a group, so this is usually not a significant issue. In scenarios where referral sources are not shared, referring doctors tend to be closer to retirement and generationally comparable to those whom they refer to. Speaking with the outgoing doctor to learn about their practice patterns and means of communicating with their referring providers is important to ensuring a smooth transition.


Can you identify any difference in approach for ophthalmologists versus optometrists?

Dr. Chiang: I have found that general ophthalmologists prefer a brief meeting in person, whereas optometrists enjoy dinner lectures on various hot topics in retina. On the other hand, ophthalmologists seem to highly value events where they can collect CME while quickly brushing up on the latest in management of retinal diseases. However, these are just generalities. Find out from your partners what has worked in the past for your practice while concurrently asking referring providers what they prefer, as their needs and desires may change over time.

Dr. Vander: My impression has been that optometrists tend to be a little more likely to refer based on their impressions from an educational dinner or meeting, whereas ophthalmologists are more likely to stick with colleagues with whom they have trained or worked.

Do you look for anything specific with regard to referrals when signing a contract to join a practice?

Dr. Chiang: As I alluded to previously, it is essential to know the expectations of the position. How did the practice come up with this position? Is it a brand new venture into uncharted territory for the practice? Is it the result of a merger? Is it filling the shoes of a retiring partner? Knowing the details of the position itself will give you a sense of how much initial legwork will be involved. However, one thing you can be sure of regardless of the situation is that you will be new to the referring doctors and it will take some effort and time to get established.

Dr. Vander: If you are expected to develop your own referral sources, it is completely appropriate that your contract provide you with a reasonable budget. You are coming into a new practice with limited financial resources and going out to dinner or a ballgame can be part of generating those sources. Specifics for entertainment and referral business development should be explicit. n

Section Editor Murtaza Adam, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Section Editor David Ehmann, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Section Editor Sundeep Kasi, MD
• second-year retina fellow at Wills Eye Hospital in Philadelphia, Pa.

Allen Chiang, MD
• attending surgeon, Wills Eye Hospital retina service; physician, Mid Atlantic Retina; assistant clinical professor of ophthalmology, Thomas Jefferson University, all in Philadelphia, Pa.

James Vander, MD
• president of Mid Atlantic Retina; clinical professor of ophthalmology at Thomas Jefferson University, both in Philadelphia, Pa.


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About Retina Today

Retina Today is a publication that delivers the latest research and clinical developments from areas such as medical retina, retinal surgery, vitreous, diabetes, retinal imaging, posterior segment oncology and ocular trauma. Each issue provides insight from well-respected specialists on cutting-edge therapies and surgical techniques that are currently in use and on the horizon.