Available, Affable, Able: The 3 A’s of Medical Referrals

There is a hierarchy within medicine, the referral food chain. At the top are the predators, specialists doing procedures and interventions and getting the big bucks. Towards the bottom are the primary care providers, who provide the patients to those predators through their referrals. Ask any top predator specialists, and they will tell you that the care and feeding of their primary care referring physicians is vital to their successful practices. This qualitative study (no p-values) surveyed 21 primary care physicians in “a large primary care network in the Northeast US.” [1]

The primary care physicians (PCP) were predominantly women in family or internal medicine serving a mix of ages and geographical locations, roughly 40% with less than ten years of practice and 60% for longer. A reasonable mix of practices with the caveat that most were in an academic network, making them employees. From the point of view of referrals, maintaining patients within the network is often monitored and enforced. The other caveat is that often patients are referred to practices rather than specific members of that practice, but as we will see, that is not an issue.

The interviewers first questioned the PCP on how they select medical treatment, prescribing medications. PCPs used decision support tools, such as guidelines, to prescribe specific medications for a given clinical indication tailored to the needs of their patients. Given our information on the efficacy and adverse consequences of medications, it is a straightforward process.

But in prescribing specialist care, there is a knowledge gap in the efficacy and adverse consequences. And that brings us to the three A’s alluded to in the title. Available is a no-brainer; if the specialist has no time for the patient, they will not be called. This A may be a holdover from years ago when solo or small practices were predominant. Today, with every increasing group size, availability is probably no longer a concern.

Affability remains quite important. From the PCP’s point of view, they want to make the referral as frictionless as possible for themselves and their patients. They do not want to hear that their patient had a bad experience, was kept waiting, or had a problem. They only want to hear thank you, which applies to both patient and the specialist physician. They also want the specialist physician to provide them with follow-up, preferably before the patient tells them, so they can avoid surprises and being left out of the therapeutic loop.

Able is the toughest of the A’s, which the PCPs in this survey cited as the greatest difficulty. Reputation is not necessarily equivalent to quality or its metrics; even quality metrics may not account for the severity of the illness being managed. So how is the PCP supposed to decide? One solution the authors offer is to have specialists’ efficacy and adverse events in a decision support tool, like the medications. Given the vagaries of data collection and risk adjustment, that tool would not be near as accurate as the information we have on pharmaceuticals; and there would be a great deal of resistance to such a dataset among the specialists.

For a physician entering a practice, the older members will direct them to the specialist they most often refer patients to – based on availability and affability. Affability extends beyond professional interactions; physicians have friends, church, and other social networks creating the necessary affability. The specialist's ability will be based on the anecdotal experience of the older practice members; you are only as good as your most recent case.

You would think that experience would allow ability to be sorted out and stratified over time. But here is a dirty little secret, affability can trump ability. Some PCPs just do not see the lack of ability. Perhaps the differences are slight, or the specialist frames the patient as a “complex” case. From my study of referral patterns within a hospital system, I can report that like “birds of a feather,” the able cluster amongst themselves as do the less able. At least to the degree that length of stay, discharge disposition, and readmission are measures of ability. The competence of the PCP is often reflected in their choice of specialists – the ablest find one another, just as the less-than-able find their peers.   

[1] Given all of the authors are from the University of Pennsylvania, it is a good bet that this is the network under review.

Source: Factors Associated With Primary Care Physician Decision-making When Making Medication Recommendations vs Surgical Referrals JAMA Network Open DOI: 10.1001/jamanetworkopen.2022.56086