For the case of this example , let’s assume that the patient has axial back pain with unilateral lower extremity radicular complaints and no weakness, or numbness, and is 2 months from a lifting injury.

As one might expect, the role of PROVIDER 1 (first to patient) is a complex one, and is based on community resources and services rendered. For example, a patient living in rural West Virginia would likely see their community primary care provider (PCP), where a referral would be made to whomever is the specialty available in the area, which could be a neurologist and physiatrist, pain physician, orthopedic spine surgeon, or a neurosurgeon. The approach and the services offered to the patient are markedly different based on the specialty of the provider. For instance, if the patient were to go to a neurologist, likely physical therapy and neuropathic pain medications would be initiated. Being evaluated by a surgeon would likely lead to a surgical opinion being rendered. If the patient went to a pain physician, likely physical therapy and an epidural would be offered. Depending on the success or failure of the conservative (and geographically regional) care, the patient may need to see another provider to complete the treatment algorithm (PROVIDER 3).

Further, the patient in this rural center is unlikely to seek subspecialty resources for an opinion (PROVIDER 2) first and ultimately bypassing the community primary care provider in this rural setting. If this same patient lived in San Francisco, the reliance on a referral from the PCP is less, creating a potential need for direct-to-patient (or consumer) marketing.

This point of this divergent algorithmic approach can be underscored at a major tertiary care academic facility. One would expect that if a patient called the academic facility with the presentation of the above complaints, they would be routed uniformly through a treatment approach, under the umbrella of care. Indeed, this is not the case, and depending on the operator that answered the phone, the patient could be directed to physiatry, neurosurgery, orthopedic surgery, vascular surgery, pain management, or physical therapy.

The dependence of the patient on this gateway of care is vital to appreciate. Patients will follow the algorithm and treatment pathway their physicians put into motion, demonstrating the importance of having a keen understanding of your position in this algorithm and where to place the patient within the scope of your practice and those in your referral network.

As can be expected, the physician’s practice setting influences these defined pathways; however, the principles of relationship and network building are the same. The longitudinal philosophy of a linear referral care model is antiquated. The Provider Referral Model has evolved appropriately to look more like Fig. 8.1. Of most change in this evolution is the ability of the patient to have an interchangeable flow between the PCP and specialist that is fluid and easily adjusted.