How do referrals exactly work?

[lostintime]

How do family doctors know who to refer their patients to? And how do specialists actually get referrals/patients? Is it all based on reputation? So if family doctor A knows that specialist B is super amazing in nephrology, then they'll always refer to specialist B and specialist C, D could be left to dry with no patients?

Like does it ever happen that specialists don't have enough patients and are left twiddling their thumbs because they don't have enough of a reputation/connection ultimately leading to referrals?

[physiology]

Yes - I know one specialist who moved here after his residency. He didn't know anyone and the initial flow of patients was very slow.

Advertising and calling up family physicians did not provide enough referrals. In the end, he started giving pharma-sponsored talks / dinners to GPs, and gained the publicity needed to generate a proper referral base.