Relationships between primary care physicians, specialists may affect patient satisfaction

Patients' care satisfaction may increase when their primary care physician (PCP) has trained with the specialist to whom they are referred, a recent study found.

Researchers performed a quasi-experimental study to estimate differences in experiences with specialist care reported by patients of the same PCP when the specialist and the PCP did versus did not co-train. They defined co-training as PCP-specialist overlap in medical school or postgraduate medical school training at the same institution for at least one year. The study's primary outcome was a composite of patient-reported experiences with ambulatory specialist care according to the Press Ganey Medical Practice Survey. Specialists were included from the fields of allergy and immunology, endocrinology, rheumatology, cardiology, neurology, pulmonology, dermatology, urology, general surgery, obstetrics and gynecology, reproductive endocrinology and infertility, orthopedic surgery, and neurosurgery. Results of the study were published Jan. 3 by JAMA Internal Medicine.

Of 9,920 specialist visits for 8,655 patients, 306 (3.1%) involved PCP-specialist pairs who had co-trained. Co-training ties between PCPs and specialists were associated with an adjusted composite patient rating of specialist care that was 9.0 percentage points higher (95% CI, 5.6 to 12.4 percentage points; P<0.001) compared with patients of PCPs and specialists that did not co-train. The researchers noted that the association was stronger for PCP-specialist pairs who had full overlap in training (i.e., those who were in the same class or cohort) and was consistently strong for almost all aspects of patient experience, such as clarity of communication and engagement in shared decision making.

Co-training was also associated with changes in drug prescribing, suggesting behavioral changes beyond interpersonal communication, the study found. PCP-specialist co-training was associated with a 1.6 percentage point (95% CI, 0.3 to 2.9 percentage points) higher adjusted proportion of specialist visits in which patients were prescribed a medication and a 1.2 percentage point (95% CI, −0.7 to 3.0 percentage points) higher adjusted proportion of visits with imaging ordered, although the latter estimate was less precise. The proportion of patients for whom a follow-up appointment was recommended did not differ by co-training. Results were similar in analyses that looked only at instances when PCPs did not specify a specialist, and concordance between PCPs and specialists in age, sex, medical school graduation year, and training institution (without requiring time overlap) was not associated with better care experiences.

The authors noted that co-training was not common and that response to the patient surveys was low, among other limitations. They concluded that their study suggests potentially large gains in quality from encouraging and harnessing physician-peer relationships. “Taken together, these findings are consistent with the notion that peer relationships can motivate physicians to deliver improved care through peer or audience effects; when physicians believe their work may be scrutinized or recognized by peers, they may aspire to higher standards,” the authors wrote. “Referrals from familiar PCPs should make alignment of values more visible, thereby establishing stronger peer accountability and offering an opportunity for the specialist to demonstrate what is valued by the related PCP-specialist dyad, including competence and patient-centered care.”

An accompanying editorial discussed the importance of nonfinancial incentives and of physicians' intrinsic motivation to act professionally. “Creative organizations may find additional ways to encourage and to benefit from physicians' intrinsic motivation. Two additional questions—questions that have received little attention in organizations' drive to expand—are highly relevant,” the editorialist wrote. “First, how (if at all), can large organizations structure some degree of human scale into the settings in which physicians engage with each other and with patients? Second, what effects do very large organizations have on intrinsic motivation, and how can they support and build on this motivation?”