Editor’s note: Doximity Advisory Board member Elise Singer, MD, is a
practicing primary care physician in San Francisco and the Chief Medical
Officer at California Health Information Partnership & Services Organization.
In a single year, the average primary care physician refers patients to 229
specialists working in 117 separate practices, according to the Annals of
Internal Medicine. On paper, it’s a staggering number. Yet in context it makes
more sense. Any doctor within the medical system is only one degree away from a
primary care physician, and PCPs are often the first office visit a patient
makes. As such, PCPs acquire an extensive understanding not only of how the
healthcare system works, but also of who the players are. And that extends to
subspecialties–the neurologist who does Parkinson’s, for example.
My own first practice outside of my formal training was in Camden, New Jersey.
From the beginning I was seeing extreme things. Half of my patients were
diabetics, many coming in with glucose levels of 400 for first-time diagnoses.
Most didn’t speak English. I needed quite a few referrals, and the situations
were so acute, I needed them quickly. I was calling everyone–the operator, my
residency (which was back in Seattle), our GI guys. Ultimately, another
physician practicing in Camden became my savior. He knew everyone.
For PCPs, there are countless permutations of this story, be it a matter of how
serious the cases, how varied their nature, or how heavy the patient load. All
really represent a gateway challenge in our profession: Building referral
networks. Indeed, when physicians need to move they have an intuitive
understanding that they’ll lose all those contacts. That loss is a big deal.
Especially in primary care, where the volume just gets so high.
With this in mind, what’s baffling perhaps isn’t so much how we get to 229,
it’s how we keep it up. Getting someone on the phone–when you need to–is just
so painful. First you get a receptionist, then you’re transferred to a medical
assistant, then you wait while that MA finds the doctor. Then, the MA calls you
back–which sometimes involves your receptionist or MA getting you, and finally
once the MA hears you on the line, that person can finally go ahead and connect
you with the doctor. In my experience, the least amount of time all this can
take is 15 minutes, and realistically it can often be hours. If you’re
determining whether a patient needs to be seen that day or not, that’s pretty
Now, too, there’s a whole new layer starting to build. We’re trending toward
hospitalist medicine, and PCPs and specialists alike are getting absorbed into
larger systems that are by nature more insular. I especially wonder how these
changes will impact PCPs moving to new communities, where mixers, social
events, and grand rounds helped facilitate connections. What we do have today,
of course, is technology.
With Doximity, we’re getting at some of these challenges by developing a
precision referral system, meaning that our data can help you quickly hone in
on what you need: such as specialty, location, insurance accepted, and
languages spoken. To make results even more specific, we’ve appended PubMed
profiles, so within that same search you can find and reach a doctor who’s
worked on something incredibly specific, like retinoblastoma. To underscore
what we’re trying to do, the Dox programmers and I thought we’d have a little
fun and illustrate the current PCP referral process for you as I’ve experienced