Sabrina Alexander walks into a hospital and happily greets a doctor.

Hi Dr. Cepeda, she says.

A meeting like this may be the reason your primary care doctor recommends the next specialist you see. Alexander spends most days visiting different physician's offices, armed with brochures touting the qualifications of the doctors in her orthopedic group.

The things that I can do really help my specialists shine to other primary care physicians and help them stand out against the- our competition, said Alexander.

She's part of a growing new industry. Front line go-betweens like Alexander --- and even entire marketing firms --- are hired by specialty physicians to get the word out about their expertise.

Oftentimes that is the only way that we learn about a new doctor in town, said Pediatrician Dr. Michael Cepeda.

Busy primary care doctors, like Dr. Cepeda, don't spend as much time in the hospital meeting other specialists. Instead they're booked solid in their offices, so Dr. Cepeda says he's happy to meet with specialists' representatives.

Whenever I need another resource they're the best way for me to find out what else can be done for your health care, he said.

But critics worry these office-to-office pitches.

I don't think patients have the vaguest idea of, uh- that their referral might have been the result of a marketing campaign, says bioethicist Lawrence Nelson.

Nelson hopes primary care docs are basing referrals only on specialists' qualifications.

The best protection for patients is physicians who are following their ethical obligation to make referrals based upon the patients need and personal preferences and not on slick marketing or any kind of other inducements, Nelson said.

The American Medical Association says there are strict ethical guidelines and laws regarding patient referrals, similar to rules regulating pharmaceutical sales reps. Physicians have to be knowledgeable about a specialist's experience and can't accept referral fees.

My job is to refer my patients to whoever I think is going to provide the highest level of medical care in that situation, said Dr. Cepeda.

Experts say patients should always ask any specialist they're referred to basic questions like: Have you seen problems like mine before? How many patients have you treated with this condition? and, What were the outcomes?

In the past decade, the number of patients referred to specialists has doubled.

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