Patients report better care with specialists their PCPs know

Patients were more likely to report receiving better specialty care if their primary care physicians referred them to specialists who the PCPs knew, according to research published in JAMA Internal Medicine.

Maximilian J. Pany, an MD-PhD candidate in health policy at Harvard Medical School and Harvard Business School, said in a press release that “interactions between PCPs and specialists are a bedrock of medicine.”

“Given the communication and collaboration inherent in caring for referred patients, we were wondering whether prior PCP–specialist relationships influence that care, especially as experienced by patients,” Pany said in the release. “Not only are patient experiences an important dimension of quality of care, but we thought they may also be responsive to physician efforts to demonstrate their professionalism given the medical profession’s emphasis on patient-centered care.”

Pany and J. Michael McWilliams, MD, PhD, the Warren Alpert Foundation Professor of Health Care Policy at Harvard Medical School and a general internist at Brigham and Women’s Hospital, conducted a quasi-experimental study to better understand how peer relationships between specialists and PCPs that were formed during training might affect specialist care for patients. The analysis was based on electronic health records of 8,655 patients who were referred to a specialist between 2016 and 2019.

The researchers analyzed how ratings of specialist care differed between two groups: patients who saw a specialist who trained with their PCP and those seen by specialists who did not train with their PCP.

They also looked at referrals distributed to specialists by scheduling systems rather than those in which a PCP requested a specific specialist to “isolate the causal effect that we would see if patients were randomized to specialists,” according to the release.

Pany and McWilliams found that if the consulting specialist trained with the PCP, “patients reported substantially better specialist care” than patients of the same PCP referred to the same specialty — an association that was “not expected from differences in performance between the same specialists in the absence of PCP-specialist co-training ties,” the researchers wrote.

“Co-training was not only associated with a more friendly and concerned manner, but also clearer explanations, greater engagement in shared decision-making, and changes in prescribing by specialists,” they wrote.

Additionally, “patients’ ratings of specialist care were markedly higher when the specialist and referring PCP trained at the same time at the same institution, particularly when in the same year, and were thus more likely than other PCP-specialist dyads to have a strong peer relationship established.”

Of the 9,920 total specialist visits studied, including 502 specialists in 13 specialties, 3.1% “involved PCP-specialist dyads with a co-training tie.”

When present, co-training ties were linked to a 9-percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4), “analogous to improvement from the median to the 91st percentile of specialist performance,” Pany and McWilliams wrote.

“This association was stronger for PCP-specialist dyads with full temporal overlap in training (same class or cohort) and consistently strong for nine of 10 patient experience items, including clarity of communication and engagement in shared decision-making,” they wrote.

McWilliams said in the release that “what we think we uncovered here is the power of peer relationships in medicine, which has major implications for how care is organized and how physicians are, loosely speaking, managed.”

“What drives physicians to excel is primarily not money,” he said. “Policymakers have been trying for years to try to pay for quality, with little success. What our study suggests is that physicians’ intrinsic motivation runs deep — it’s there but often undermined by our system. We need to do a better job of tapping into it.”

Pany and McWilliams wrote that the findings indicate that “strategies encouraging the formation of stronger physician-peer relationships” could offer significant potential gains in quality of care.

McWilliams said in the release that “there are a bunch of strategies” physicians could use to apply and operationalize these findings in practice like “team care in which physicians can observe each other’s decision-making and lead by example” and making physicians “more visible to each other when they collaborate on patient care — for example through e-consults, virtual curbside consults, or other back channels that breed familiarity.”

“Another is to use modes of collegial peer review such as group case discussions more often and more effectively. Imagine knowing that any patient encounter or surgical case could be randomly selected for discussion over lunch with valued colleagues,” he said. “We could also identify exemplars and redeploy them as coaches. And more generally, do anything that makes the practice of medicine less lonely — for example, move the workstations out of the exam rooms to a communal space where physicians will naturally interact with each other.”

References:

• Pany MJ, et al. JAMA Intern Med. 2022;doi:10.1001/jamainternmed.2022.6007.
• When doctors know each other. https://hms.harvard.edu/news/when-doctors-know-each-other. Published Jan. 3, 2022. Accessed Jan 3, 2022.