Patients receive better care when specialists know referring physicians

Are you likely to get better care if the specialist treating you knows your primary care doctor?

The answer appears to be yes, according to new research from Harvard Medical School published Jan. 3 in JAMA Internal Medicine.

Patients under the care of specialists who trained with the patients’ primary care physicians (PCPs) reported that they treated them in a more concerned manner, received clearer explanations, and experienced greater involvement in making shared decision-making, among other benefits, the study found.

The findings suggest that strategies that foster stronger relationships among physicians could lead to significant improvements in the quality of patient care, the authors said.

The analysis is based on electronic health records of more than 8,600 patients referred by their PCPs to see a specialist between 2016 and 2019. All referrals occurred in a large academic health system. The researchers compared patient ratings of specialized care between two groups of patients; those cared for by a specialist who trained with the patient’s PCP in medical school or graduate programs, and patients of the same PCP cared for by a specialist who did not train with their PCP, while monitoring the specialist’s performance for those patients of other PCPs when such training ties were absent.

Importantly, the researchers looked at referrals that were distributed to specialists through a scheduling system rather than referrals where PCPs requested specific specialists. In this way, the team was able to isolate the causal effect that we would see if patients were randomly assigned to specialists.

Harvard Medicine News discussed the implications of the findings with the study’s first author, Maximilian Pany, an MD-PhD candidate at HMS and Harvard Business School, and lead author J. Michael McWilliams, a Warren Alpert Foundation professor of health care policy at HMS and general internist at Brigham and Women’s Hospital.

HMNews: What sparked your interest in the interplay between patient satisfaction and the prior connections between primary care physicians and the specialists who treat them?

Pany: Interactions between PCPs and specialists are the foundation of medicine, and specialty referrals are the way much aftercare is set up. Given the communication and collaboration inherent in the care of referred patients, we wondered if prior relationships between the PCP and the specialist influence that care, especially what patients experience. Patient experiences are not only an important dimension of quality of care, but we think they may also respond to physicians’ efforts to demonstrate their professionalism given the medical profession’s emphasis on patient-centered care.

HMNews: What aspects of care improved?

Pany: We found that patients referred to specialists by co-learners rated their specialists higher on nearly every dimension we examined. This includes not only interpersonal communication -; such as kindness, the quality of the explanations and the concern shown -; but also the participation in shared decision-making, the use of understandable language and the amount of time spent. In addition to higher patient ratings, co-training led to changes in specialists’ prescribing behavior, suggesting an impact beyond (very important!) patient perception.

HMNews: What do you think explains this difference in performance?

Pany: We believe the driver at play is that specialists are aware that PCPs can look at aspects of their care; through reading clinical notes and talking to patients, for example. The existence of a strong peer relationship can remind specialists of commonly valued precepts of professionalism or motivate them to change care in ways that have a positive impact on patients.

HMNews: Did this finding surprise you in any way or did you suspect that it might?

Pany: While not surprising in theory, we were surprised by the magnitude of the impact we found. I suspect that most of us have experienced situations, not necessarily related to medicine, where we wanted to excel because we knew we would be watched by family members. If the presence of peers whose opinion matters to us motivates better performance in, say, soccer games, why not in a professional context like medicine? It is a fundamentally human phenomenon.

HMNews: What are the broader implications of these findings?

McWilliams: What we think we discovered here is the power of peer relationships in medicine, which has important implications for how care is organized and how doctors are managed, more broadly. During training, physicians form strong relationships with other physicians, but we often practice in isolation; this despite the fact that most of us now work in employed groups and use advanced information and communication systems that should make it easier for us to interact. Essentially, we have grouped and connected doctors electronically, but we haven’t taken advantage of what doctors can offer when grouped or connected.

I would say that there is another high-level political implication of the dramatic effect that we found: what drives doctors to excel is mainly not money. Policymakers have tried for years to pay for quality, with little success. What our study suggests is that the intrinsic motivation of physicians runs deep; it is there, but often undermined by our system. We have to do a better job of taking advantage of it.

HMNews: How should these findings be applied in practice to move the needle in the physician’s performance? How do we operationalize them?

McWilliams: There are a lot of strategies, and I think we can be very creative here. One is team care where doctors can observe each other’s decision making and lead by example. Another is to make doctors more visible to each other when collaborating on patient care; for example, through e-consultations, virtual curbside consultations, or other secondary channels that build familiarity. Another is to use modes of collegiate peer review, such as group case discussions, more frequently and effectively. Imagine knowing that any patient encounter or surgical case could be randomly selected to be discussed over lunch with valued colleagues. We could also identify specimens and redistribute them as trainers. And more generally, do whatever makes the practice of medicine less lonely; For example, move workstations out of exam rooms into a common space where clinicians naturally interact with one another.

HMNews: Any warning or limitation that you want to highlight?

Pany: In our study, co-training was an indicator of doctor-peer relationships, but it is highly likely that co-training ties are not the only source of doctor-peer effects. The extent to which the co-training effect generalizes to other forms of physician-peer interactions remains an exciting topic for future work.

Fountain:

Magazine reference:

Pany, M.J. et al. (2023) Physician-peer relationships and patient experiences with specialty care. JAMA Internal Medicine. doi.org/10.1001/jamainternmed.2022.6007.

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