I like what lobelsteve said and would emphasize that if you don't take care of the customer someone else will. Both the patient and the referring doctor are your clientele. That means if a surgeon sends you a lot of referrals and he wants help with postop pain management you better damn well do it because someone else who's hungrier will. I have a gentleman's agreement with the referring surgeons that I will help with postop pain on any patient that I have treated. They don't abuse that.
To me it's all about eggs and baskets. As with the stock market, you should diversify. I'd prefer lots of little baskets to a few big ones. If there is one surgeon who sends you half your business that person pretty much owns you.
I also try to be on the "gatekeeper" side of things. Therefore I have emphasized the primary care referral route rather than depend on surgical referrals (although I still have plenty of those). One thing you need to do is break the "back pain -> surgical referral" reflex. You can educate the PCPs about "red flags" that need surgical referrals vs the 99% that can wait and have conservative management first.
I usually try to make my "Impression" and "Plan" sections educational, in the hope that if someone actually reads my note they will learn how to determine what can wait and what needs a surgery evaluation. They also learn that it's not just a prescriptions-and-shots practice, but that a patient with back pain can be sent for initial evaluation and a surgical referral will be made as needed.
As a result of these efforts my referral base is wide and shallow - I get a few referrals each from a lot of people. That also gives me some control over specialist referrals - I can steer patients to the surgeons, neurologists, physiatrists, imaging, etc, that I prefer. There are few better incentives for someone to refer you patients than the fact that you are sending them patients.
The downside, as discussed elsewhere, is that when those PCPs, internists, neurologists, etc, admit a patient that needs pain management you are expected to help out with the dreaded hospital consult. I'd rather do that than be beholden to a couple of surgeons for my livelihood.
I am also not above reminding someone who I have just bailed out with a simple PCA pump or an inpatient LESI that I expect outpatient referrals in exchange for inpatient support. If I know they use someone else routinely and I am being called because that guy won't do the consult I will discuss that situation with them before I do the consult. It's usually along the lines of "I know you like to use Joe Smith, but if he isn't going to be there when you need him and I am, then perhaps you need to re-think your relationship." if I don't see referrals as a result, the next consult is declined.
If I know that doing the consult definitely won't change the referral pattern I will tell the nurses that they need to consult Dr. Joe Smith, who is the referring physician's preferred pain doctor. Usually they will tell me they already tried that, which obviously does not increase my enthusiasm for the consult. I see no need to inconvenience myself to help out someone who will not send me outpatient referrals no matter what I do.
In my area (Houston) everyone is doing deals all the time because there are no certificate of need requirements in Texas and ASCs are crowding crack dealers off of the best street corners. If a surgeon and a pain guy are partners in an ASC then that's where the referrals will go.
Some guys will see patients at the surgeon's office and pay "rent" (aka "kickback"). The problem with financially based relationships is that as soon as someone comes along with a better deal there go your referrals. I prefer not to buy my friends because then they are always going with the highest bidder.
If someone tells me they will refer me patients but they must be done at a certain facility I will do that, but that's as far as I will go.
