The power of relationships with doctors

Primary care physicians (PCPs)’ relationships with specialists affected how their patients experienced referrals and how they were treated by specialists, a study has shown.

Patients referred to specialists with whom their PCP had trained at the same institution for at least 1 year of medical school or graduate education rated their care from the specialist higher overall, found J. Michael McWilliams, MD, PhD, and Maximilian J. Pany, BA, both from Harvard Medical School in Boston.

In fact, the significantly higher 9.0 percentage point adjusted composite score compared to PCP-specialist referrals where there was no education overlap was on par with specialist moving from the 50th to the 91st percentile of performance.

Specialists were also more likely to prescribe medication, order an imaging test, or both, to patients of doctors they went to school with or studied with.

“This study suggests potentially large quality gains by fostering and leveraging physician-peer relationships,” the researchers wrote in JAMA Internal Medicine.

The results were “quantitatively” similar when looking at patients who ended up being seen by a specialist that their PCP had not referred them to but had trained with.

While more drugs or more testing wouldn’t automatically be a good thing for patients, the findings provide clues for quality improvement programs, suggested Lawrence P. Casalino, MD, PhD, of Weill Cornell Medical College in New York City. .

“It can be debated whether the desire to act professionally in the eyes of colleagues should be defined as intrinsic motivation, but in any case, this motivation, whatever it is called, is, as the authors suggest, something that organizations that provide healthcare could be used more broadly to improve quality,” he wrote in a guest comment.

There are implications for the “related and intertwined phenomena” of value-based purchasing, such as the financial carrots and sticks of the Medicare Merit-Based Incentive Pay System (MIPS), and the rapidly expanding size of the healthcare organization, Casalino added.

If intrinsic physician motivation is important, as the study suggested, “it may not be prudent for health care organizations or external entities such as Medicare to provide direct financial incentives to individual physicians, especially when they are tied, as they often are.” be”. to lower performance measures,” Casalino wrote, citing health economist Uwe Reinhardt’s argument that physicians’ motivation for high-quality care need not be “bought with tips.”

But the large regional and national health organizations that are increasingly becoming the norm are “necessarily bureaucratic and non-human in scale,” he added, undermining the smaller practical experience in which “mutual knowledge and trust, and sometimes Often, on a practical level, they are based on informative and professionally satisfying telephone conversations about individual patients.”

A key question that deserves more attention is “how (if at all) can large organizations structure some degree of human scale into the settings in which clinicians interact with each other and with patients?” Casalino pointed out.

Potential solutions in the current healthcare climate could include increased team care, electronic consultations, peer coaching and multispecialty case discussions, McWilliams and Pany noted.

Their study involved one of a large academic health system’s electronic health record data on referrals initiated by their PCPs from 2016 to 2019.

During this period, 9,920 visits to specialists were made for 8,655 patients (62.9% women; mean age 57.4) referred to 502 specialists in 13 specialties, representing 50.7% of all referrals in the system.

Among the specialist visits in the study, 3.1% involved a PCP-specialist pair where the two had been in medical school or graduate school together for at least a year. However, the associations were strongest for pairs of physicians whose training had completely overlapped, either in the same class or cohort.

The results were also consistently strong for nine of the 10 elements of the patient experience, the researchers noted, so that the co-training partners “not only elicited a more friendly, courteous and caring manner, but also clearer explanations, greater participation in shared decision-making. more time with patients and objective changes in the prescription of medications.

Patients were 1.6 percentage points (95% CI: 0.3 to 2.9) more likely to obtain a prescription at their specialist visit and non-significant 1.2 percentage points (95% CI: -0. 7 to 3.0) more likely to receive an imaging request when their PCP and specialist had trained together, after adjusting for differences between specialists observed in the absence of joint training links. The same was not true for follow-up appointment recommendations.

“Therefore, the behavioral response elicited by joint training ties appears to extend well beyond a change in behavior that might alter patient perceptions to include behavioral changes that promote patient-centered care,” the researchers wrote. .

In particular, the agreement of PCPs with their patients’ specialists in terms of physician age, gender, year of medical school graduation, and having attended the same institution at a different time was not associated with better care experiences. .

Casalino noted that one limitation of the study was its examination of only one elite healthcare system, “in which physicians are likely to have been trained in elite institutions and place a high value on that era of their lives.” Another was the definition of overlap between PCPs and specialists, because “co-trained physicians may not have even met or cared for the same patients.”

“It is possible that the results would have been even better if the relationship between the primary care physician and the specialist had been more substantial (for example, if they had seen several patients together),” he noted.