Informal consultations with colleagues are an important source of information for practicing physicians.1,3–7
However, few data are available about how these interactions among physicians are organized and whether they are structured in a way that is likely to promote timely access to up-to-date medical information. Our study provides evidence that within 1 academic primary care practice, physicians interacted with colleagues in a manner that would appear to encourage efficient dissemination of clinically relevant medical information.
Our findings support our hypotheses about factors important to the network structure within this practice. First, physicians seek out colleagues who are able to provide current and useful information. Not only were influential physicians more often self-reported experts in women’s health, they also had greater proportions of women in their panels and they had more patient care sessions each week, suggesting greater experience with women’s health issues.
Second, discussions among physician colleagues appeared to be channeled along lines of opportunity and convenience in terms of temporal and spatial proximity. Physicians practicing in the same clinic within the overall practice were much more likely to seek information from each other, suggesting that physical proximity allows for influential discussions that may not otherwise occur. Availability may also explain our finding that physicians with more weekly patient care sessions were more often cited by their colleagues as sources of influential discussions, although this finding may also reflect greater clinical expertise among these more clinically active physicians.
Finally, physicians were slightly less likely to report having influential discussions with other physicians of different gender and thus more likely to have discussions with physicians of the same gender, although this finding was of borderline statistical significance. Physicians may be more apt to seek out and be influenced by demographically similar colleagues; however, we did not observe any association between interaction patterns and professional age or years in practice. In addition, we did not find that physicians consulted women about women’s health issues just because they were women. Rather, they sought information from physicians with greater experience and expertise in women’s health, which were more frequently found among women physicians in this practice. The greater expertise among women physicians may also explain observations of higher screening rates among women patients who see women physicians.19,20
Primary care physicians’ practices should recognize that informal discussions about clinical issues are occurring with high frequency and with a clear structure, and that it may be to their advantage to understand and use these informal networks to encourage diffusion of up-to-date and high-quality information. With relatively minimal effort, a practice could help to identify content-area experts, who may already be serving as the practice’s “opinion leaders,” and make them known to other providers in the practice. A practice could also support its content-area experts by assisting them with opportunities for continuing medical education and helping them obtain recent and reliable research information Medical librarians could also play a role by helping to apprise such experts of new information.21
Primary care practices could also structure themselves so that members of the practice become content-area experts in complementary areas. Although this would require more organization, it might help to minimize unnecessary referrals to specialists and reduce additional office visits by patients. Practices could offer incentives for physicians to be recognized for content-area expertise, e.g., by encouraging them to schedule fewer patients on certain days or allocating blocks of free time during which they would be available to answer questions from colleagues. The clinical volume of such experts should not decline too much, however, as large drops could affect how others perceive their expertise. Practices could also provide bonus payments for colleagues recognized by others as helpful resources. Academic institutions could recognize the value of such expertise by considering it as a factor in promotion of its clinician educators.
Our finding that self-reported women’s health experts tend to be centrally located within the network validates those self-reports, suggesting that physicians are able to effectively identify themselves as content-area experts. Nevertheless, it is conceivable that in other practices a network might be misaligned or organized in such a way that clinicians having special knowledge and expertise in certain areas are not sufficiently accessible or well-enough known to others.
Our findings should be interpreted in light of several limitations. First, we studied a relatively small practice of only primary care physicians affiliated with a single major teaching hospital. Additional research is necessary to determine whether patterns of informal discussions among specialists, between generalists and specialists, and among physicians in different institutions and larger practices are similar. Second, we asked only about influential discussions about issues related to women’s health. Additional studies are needed to determine whether the networks for influential discussions about other topics, such as cardiovascular disease, are similar or different. Third, we studied only physicians within the practice and cannot draw conclusions about the role of physicians outside of the practice in influencing practice patterns. However, when asked to name the person in or out of the practice who is most influential on their women’s health practice, both expert and non-expert physicians predominantly cited physicians within the practice. Moreover, although we assessed the influence of prior training at the present practice site, we had limited information about prior educational relationships with other physicians in the practice which, in turn, might influence the likelihood of informal discussions.
Finally, our analytic strategy accounted for many interdependencies among network variables, and assumed that pairs of physicians were conditionally independent of one another. Other forms of interdependence are possible, however, such as “clustering” in which, for example, physician A is more likely to cite Physician C if physician A cites physician B and physician B cites physician C. Our “same clinic” predictor took some, although not all, such clustering into account.
In summary, informal discussions among physicians that influence clinical practice are frequent. Our data suggest that these discussions are clearly organized within a network of physicians in a hospital-based primary care practice. In addition to the influence of opportunity and convenience on these interactions, physicians also identified colleagues who had higher levels of experience and who were self-reported women’s health experts. Recognition that networks of influential discussions are common within practices could potentially help to promote more rapid dissemination of high-quality evidence-based medicine within primary care settings.