Influence of client/colleague dependence on physician performance in patient care.

The study has attempted to determine how client/colleague dependence influences medical care received by patients. We have tested physician compliance with standards of care according to the degree to which the practice is visible to, and dependent upon, colleagues. Physician performance is measured in terms of compliance with established professional standards in five areas of practice: 1) the quality of medical care; 2) appropriateness of hospital admissions; 3) appropriateness of length of hospital stay; 2) overstays and 5) understays. The sample consisted of 3316 hospital episodes from 22 general hospitals in the state of Hawaii, and the analysis was conducted via multiple-classification analysis (MCA). Specifically, it was found that from the more colleague-dependent physicians, patients received care with: 1) higher scores on an index of quality of care; 2) more justified admissions; 3) more appropriate lengths of stay; 4) fewer overstays; but 5) more understays. These results remained even after adjusting for a number of physician, client and type-of-practice variables. The findings of this study suggest the significant role that the informal structure of physician practice plays in influencing physician performance. Various sociological implications for control of professional practice are discussed in terms of 1) provision of incentives to encourage an increase in the formalization of otherwise informal physician relationships, and 2) tying formal control mechanisms to informal processes of control.