In a span of one month in late 2008, the following four incidents were reported. In one case, a practice representative on the East Coast was making the rounds to shore up CT referrals. She reported that the referrals from one office had dropped dramatically because the referrer’s faxes would not go through. In another incident, a practice representative in the Midwest was attending a sponsored lunch at a group practice where two out of the seven physicians were referring patients for imaging. One of the five nonreferring physicians discovered, during the visit, that a radiologist at the imaging center had been a fellow student at his former medical school. He sent over his first patient about an hour after the lunch. In a third case, after a PACS installation, a representative on the West Coast remarked to the referring physician that in his experience, the center with the PACS icon on the computer at the referring office is the one that gets the scans. The physician acknowledged that was true. In the fourth incident, in the Southwest, the referrals at another office dropped due to fax problems. These reports are important for a few reasons. First, they point out the important role played by practice representatives, the so-called feet on the street. In each case, the representative was there either to provide a valuable service or to overcome an obstacle to more referrals. Without that physical presence, business would have continued to decline. Second, these stories reveal the sensitivity of some referral relationships. All four of the radiology practices in the these anecdotes are good in all the important areas; that is, their equipment is advanced and their radiologists are highly qualified. None of that mattered to the referrers at the time, however. What mattered to them were a few of the operational and personal issues that we often take for granted, such as ease of communication and physician-to-physician relationships. Imagine: Faulty fax machines interfered with two otherwise healthy, lengthy referral relationships. The chances are good that in those fax incidents, the decision to send scans elsewhere was not made by the referring physician, but by an office manager, physician assistant, or referral coordinator further down the referral chain.
Figure. Unattended customers fall into the zone of indifference Third, and perhaps most important, these stories underscore the need for you to increase your brand awareness, making your imaging business something so special and different that it becomes immune to the small problems that arise now and then. Promoting your unique brand is the best way to avoid the commoditization of your practice. Left to make their own decisions, many offices will default to what is easiest (to the path of least resistance). Left on their own, your referrers will fall into the zone of indifference. This term was coined by Robert Strausz-Hupé (1903-2002) in his 1952 book of the same name, but Strausz-Hupé’s book was about historical perspectives on the relationship between the United States and Europe, not about customer service and the personal relationships central to any successful business. Over time, the term took on new life as a way of explaining what could happen to customers (in your case, referrers first, and sometimes patients) when no one pays attention to them. As you can see in the figure, the zone has two bars, each with degrees of satisfaction or dissatisfaction ranging from high to low. As your customers pass from one end to the other, they move through the zone of indifference, the most dangerous position on the chart. It is here that you are forgotten, where you become just like the other guy: not particularly good or bad, just a so-what or a shrug of the shoulders, because decision makers can’t recall why it was so important to refer to you. Here’s how dangerous the zone is: I would rather have someone stark-raving, foaming-at-the-mouth mad at me than in the zone of indifference. That angry person, you see, is talking to me, and that gives me the opportunity to correct a bad situation. Even if I can’t correct it, at least I might have some idea of how to prevent it from happening with someone else. People in the zone, however, don’t care to pick up the phone to compliment you or to complain. If something goes wrong, they will just send their patients down the street. Even if you’re doing a good job, scans might still be sent elsewhere if that is easier, for any reason, or if a competitor happens to pay more attention. Having customers in the zone is often an indication of some complacency on your side. This is a culture to be avoided at all costs. Here are three indications that your referrers are drifting into the zone:

• scan volumes are reduced,
• telephone calls or other messages do not get prompt responses, and
• referral decisions move from the physician to the staff.

There are simple ways to keep referrers out of the zone. In addition to your written report, make an occasional phone call with your findings. Send at least one thank-you note per week to a key referrer. Host an educational lunch or breakfast for your top referring offices. In addition, don’t forget to check your fax machine from time to time.