Physician peer relationships may hold key to improved care quality

What motivates doctors to provide high-quality care? Most payers and health care institutions assume it’s financial reward. But a new study suggests the answer lies instead in doctors’ relationships with their peers and desire to demonstrate their competence and professionalism to them.

The study’s authors sought to determine whether specialists provide better care to patients referred by primary care physicians (PCPs) with whom they had trained. They analyzed 8,600 patient ratings of nearly 10,000 visits with specialists, comparing ratings of visits with specialists whose training overlapped with the referring PCP in medical school or postgraduate programs with those of patients referred by the same PCP to a specialist who hadn’t trained with the PCP. The visits occurred at a large academic medical institution between 2016 and 2019.

They found that co-training ties between PCPs and specialists were associated with a 9 percentage higher composite patient rating of specialists care as measured on the Care Provider domain of the Press Ganey Medical Practice Survey. That difference is equivalent to improving from median performance to the 91st percentile of quality for specialists.

The authors say the data also suggest that specialists whose training overlapped with the referring PCP were more likely to demonstrate the type of behavior that promotes patient-centered care, including showing more concern for the patient, spending more time with them, and engaging in more shared decision-making.

Such behavior, they explain, stems from “peer and audience effects”: specialists know the referring PCP can observe the care they provide by reading their notes and talking to patients. Thus “an audience of familiar peers may elevate physician performance, not only by subjecting it to informed scrutiny but by providing an opportunity to demonstrate commitment to what is valued by the profession.”

Taken together, the authors say, the co-training effects of patient ratings on specialist care are greater than those of other policies and interventions aimed at improving patient experiences such as public reporting, participation in accountable care organizations, health plan effects and hospital characteristics. Consequently, their findings “could have major implications for the organization of care delivery, as they suggest potentially large quality gains from models encouraging peer interactions,” including team-based care, peer coaching, and multispecialty case discussions.

In addition, they note, strategies aimed at harnessing physician professionalism and the pressure to live up to colleagues’ expectations “could generate gains over many dimensions of care without requiring decision-specific interventions that risk erosion of intrinsic motivation when deployed in aggregate.”

The study, “Physician-Peer Relationships and Patient Experiences With Specialist Care,” was published online January 3 in JAMA Internal Medicine.