I'm in a similiar situation and have similiar beliefs. In Northeast Connecticut, while I have some options, there aren't alot of choices. I try to do some personality matching if possible (i.e. of the 2 oral surgeons I refer to, 1 has more of a "touchy, feely" personality and one is a cut right to the case type of guy. I though don't have any reservations about sending my patients to a specialist that may be located further away based on treatment philosophy or skill level. Lastly, but certainly not least, you listen to patient feedback. If I'm hearing alot of negative feedback, I'm either having lunch quickly with the specialist and voicing my concerns, or referring elsewhere. Example, when referring for implant placement, my patients travel about 40 miles to an oral surgeon. In the same town as this oral surgeon, is a renowned oral surgeon who lectures internationally and is actively involved with ITI and their clinical research. This guy while clinically excellent has at best awfull patient skills, and therefore none of my patients business. 😉