Referrals, quality of care and the human connection

As a health economist who likes to think about the world in a quantitative manner, I do whatever I can to measure quality in a numeric manner. Thus, if I was visiting a primary care physician (PCP) and needed some specialist care, I would want the PCP to refer me to the specialist with the best quality ratings.

However, a recent paper by Pany and McWilliams (2023), the authors found that specialists often perform better when they have a personal relationship with the PCP. The PCP-specialist linkage is determined based on whether they trained at the same medical school at the same time (“co-training”). Using this approach, they write:

Of 9920 specialist visits for 8655 patients (62.9% female; mean age, 57.4 years) with 502 specialists in 13 specialties, 3.1% (306) involved PCP-specialist dyads with a co-training tie. Co-training ties between PCPs and specialists were associated with a 9.0 percentage point higher adjusted composite patient rating of specialist care (95% CI, 5.6-12.4 percentage points; P < .001), analogous to improvement from the median to the 91st percentile of specialist performance. This association was stronger for PCP-specialist dyads with full temporal overlap in training (same class or cohort) and consistently strong for 9 of 10 patient experience items, including clarity of communication and engagement in shared decision-making. In secondary analyses of objective markers of altered specialist practice in an expanded sample of visits not limited by the availability of patient experience data, co-training was associated with changes in medication prescribing, suggesting behavioral changes beyond interpersonal communication

Also, it did not appear that PCPs refer specific types of patients to their specialist colleagues, as patient characteristics did not differ depending on whether the specialist co-trained or not. In short, following your PCPs referral recommendation may not only be beneficial as a quality signal for the average patient, but a PCP’s personal relationship with the specialist may also lead to better care.