In Survey, Doctors Report Providing “Too Much Care”

According to a new survey, nearly half of primary care physicians believe that their patients are “receiving too much care;” mostly in the form of unnecessary tests and referrals to specialists. More than one-quarter of these doctors believe that they themselves are practicing too aggressively, and they tend to blame the fear of malpractice suits for their actions. Meanwhile, when asked about their colleagues; including nurse practitioners and medical sub-specialists like cardiologists, allergists, gastroenterologists, etc., the surveyed doctors indicated that financial incentives were most likely driving over-treatment.

These are just some of the intriguing findings from the survey published in this week’s Archives of Internal Medicine that involved some 600 primary care doctors who treat adults across the U.S. The authors of the report, led by Brenda E. Sirovich and colleagues at the VA Outcomes Group and Dartmouth Institute for Health Policy and Clinical Practice, consider primary care doctors “the frontline of health care delivery,” by virtue of the fact that they “both manage their own patients and are the source of most referrals to other physicians” and “are at least indirectly responsible for initiating the cascade of health care utilization (testing, therapies, and hospitalizations) for most patients.”

Utilization is at the heart of rising health care costs; any effort to “bend the cost curve” will entail reducing the estimated 30% of all care that is deemed unnecessary. Yet as defenders of this “frontline” of health care delivery, primary care doctors still seem deeply conflicted; they acknowledge that patients are receiving “too much care,” but seem confused about how best to remedy this problem.

Physicians identified three major factors that cause them to practice more aggressively: malpractice concerns (76%), required tests and interventions to meet clinical performance measures (52%) and inadequate time spent with patients (40%).  According to the Archives report, some 83% of physicians thought they could “easily be sued for failing to order a test that was indicated”—even though there is little evidence to back this up. And while only a mere 3% of physicians indicated that financial considerations influenced their own practice style, almost 40% believed that “other primary care physicians would order fewer diagnostic tests if such tests did not generate extra revenue.” Almost two-thirds indicated that they thought doctors who practice sub-specialties of internal medicine like cardiology and endocrinology would cut back on testing if there were no financial incentive.

This survey is important because it indicates an overall awareness among many doctors that they are providing too much unnecessary care. Sirovich finds this “sort of encouraging,” because this acknowledgement is the first step in engaging doctors in tackling the costly and potentially harmful practice of over-utilization. She notes that many of those who took part in her survey were interested in finding out how they compare with other physicians and with other communities. “We hope and think that means that they’re open to solving this,” she told me.

Others are less encouraged. In a commentary accompanying the survey, Calvin Chou, associate professor of medicine at the University of California in San Francisco writes, “Implicit in these findings is a kind of trained helplessness—it seems that physicians know they are practicing aggressively but feel they have no recourse.”

It’s a vicious cycle: Doctors are worried about being sued while also feeling constrained by time—in order to make a decent living they feel they need to see an ever-growing number of patients each day. Instead of spending five extra minutes talking with patients they write out an order for tests or a referral to a specialist, believing that this is the best “insurance” against a lawsuit. The tests are often unwarranted, needlessly increase health care costs, can even be harmful and, perhaps not coincidentally; increase a doctor’s compensation.

Many research studies and articles have concluded that defensive medicine is not the driving force behind over-use of tests and other excess care. Plaintiffs succeed only 22% of the time in jury-decided malpractice cases; and more times than not, lawyers refuse to take on any but the most devastating (and costly) cases. As Maggie wrote in a recent post titled, “Myths of Medical Malpractice,” “adverse events due to negligent practice rarely result in a lawsuit.” The malpractice crisis is one of perception, not hard facts.

But anecdotally, doctors continue to believe that they are at high risk of being sued. Sirovich recalls an interview she conducted with one primary care doctor who took part in the Archives survey; “He told me, ‘When I wake up in the morning my first priority is not to be sued.’” He is not alone. In a previous post, I cited findings from a study (also from the Archives of Internal Medicine) that 91% of surveyed physicians believe that they and their colleagues order more diagnostic tests and procedures than are needed in order to protect themselves from malpractice suits.

Meanwhile, some 40% of the doctors surveyed by Sirovich indicated that another reason they practice more aggressively is because they don’t have adequate time to spend with patients. It takes only a minute to write a script for a battery of tests, whereas sitting down and having a productive conversation with a patient can take 15 non-compensated minutes. Ironically, a seminal paper published in the Journal of the American Medical Association back in 1997 (and cited nearly 900 times in subsequent research articles) found that doctors get sued far less often if they spend more time with patients, engage them in conversations, use humor, and involve them in decisions about their care. The JAMA study found that doctors who had never been sued spent an average of just 3 extra minutes talking with patients when compared to those who had been sued. This surely can’t be news to anyone who practices medicine or is involved in the ever-growing field of medical risk management. Ordering tests is not going to stop patients from suing their internists; but showing compassion, interest and facilitating patient empowerment will.

The way our payment system is currently structured, there is no penalty for this frankly, indefensible rash of over-treatment. In fact, the clinical guidelines and performance measures that increasingly dictate patient care “usually set a bar for what’s enough care, not what’s too much care,” according to Sirovich.

How do we break this cycle? The answer is payment reform; the growth of accountable care organizations, medical homes, and reimbursement for episodes of care—not for each and every test and intervention. These and other structural changes, including increased compensation for the time doctors spend communicating with patients, are already occurring in demonstration projects and will be rolled out on a wider scale with implementation of the Affordable Care Act.

“Payment reform has the potential to liberate primary care physicians from their hamster-wheel existence,” writes Allan H. Goroll, Professor of Medicine at Harvard Medical School in his commentary, “When It Comes to Primary Care, More May Be More” that appears in the same issue of Archives. “The shift from paying for volume to paying for value will increasingly focus attention on care outcomes…Understanding how best to deliver that care and change patient behavior, especially in primary care settings, is going to be as important as knowing what care to prescribe.”

Meanwhile, Sirovich and her colleagues believe their findings indicate that doctors may be “open to practicing more conservatively.”

How can they best be encouraged? Beyond getting rid of financial incentives for unnecessary testing and care, the movement away from the self-reported “too much care” delivered by primary care doctors will require leadership and guidance from associations like the American Medical Association and similar professional groups. This guidance includes continuing medical education programs that focus on teaching doctors (and medical students) how to communicate with patients, to help them make informed choices, and to avoid unnecessary—and in many cases, unwanted—care. Finally, defensive medicine should be discouraged as wasteful, expensive and, ultimately ineffective in preventing medical malpractice suits.

Primary care doctors do form the “frontline” of health care delivery; and in that role they can be key players in reducing runaway medical costs while also leading the shift toward patient-centered care.

 

7 thoughts on “In Survey, Doctors Report Providing “Too Much Care”

  1. I think often unreasonable patient expectations play a role here as well. Too many patients think more care is better care and more expensive care is better care. More often than not, it isn’t. Many patients equate lots of testing with thoroughness. As long as the tests, especially expensive imaging, are not painful or invasive, patients want them “just to be sure” as long as insurance is paying the bill. They are also not shy about asking for prescriptions for drugs they saw advertised on TV when a cheaper generic or even an over the counter medication in some cases may suffice. Doctors tell me that many patients will go elsewhere if they push back too much or too often.
    I’ve also said before that defensive medicine is probably a significant factor when it comes to avoiding failure to diagnose lawsuits. Doctors don’t get sued for ordering too many tests so ordering the extra test or two provides an extra measure of protection especially when time with the patient is a serious constraint. Under the fee for service payment model, providers get paid more when they do more though I suspect that this is the least important factor.
    We could raise salaries for primary care doctors so they won’t need to see as many patients to earn an adequate income but that would just exacerbate the shortage of primary care doctors in many markets. We will probably need to make much more extensive use of NP’s over time since they can handle many of the simpler patient encounters and their income expectations are not as high because much less training is needed to become an NP. Also, patients are probably less likely to sue an NP because they don’t expect them to be as knowledgeable as doctors.
    It would also be helpful if doctors had an economic incentive to push back against unreasonable patient expectations. ACO’s might be one approach to facilitate this but a critical mass of doctors in a city or region would need to practice that way so the patient can’t easily go elsewhere to fulfill unreasonable and often expensive expectations.

  2. this confirms two bits of insider wisdom– that many docs are doing too much and they blame this behavior on others. unless and until this becomes conventional public wisdom, little will change and the public generally fears they’re being deprived of what they need. they think underconsumption is the issue, not overconsumption. given that bias, they’re unlikely to challenge providers who recommend doing more.

    • Barkley Rosser,All I was saying was that a bakaclsh that simply contained doctors’ salaries would not contain costs, unless you have a model of how they cause all the other costs (which is unlikely to be consistent with Singapore; but malpractice costs would probably go down). A bakaclsh in the form of nationalization also seems unlikely to contain costs, given how small the gap between costs in the US and France is. Costs are rising exponentially everywhere (including Singapore).You can point to a lot of sources of rising costs in health care, but even if you can get the accounting to work out, I don’t think tackling them individually will have much effect. There’s probably some central reason and the individual line items are just leaking out (eg, rent-seeking, as in both doctors’ salaries and malpractice).My impression of the claim that France has the best health care in the world is that it means that the outcomes are at the uniform level of Europe (and the US!) without problems that suggest rationing. I think Singapore passes this test as well, but that people who make these reputations are simply ignorant of it.

  3. The defensive medicine argument for over utilization is bogus. The very nature of defensive medicine is a deviation from the standards of care. So by deviating from the standards of care in order to avoid or somehow protect themselves from a lawsuit is a fallacy in every aspect; it’s those deviations that lay the groundwork for a malpractice suit. In a fee for service environment, besides re- negotiating fees (which is difficult), the only way to increase revenue is volume. You want to see costs drop overnight? Start paying for value.
    To take this pay for volume strategy a little further, what do think happens in States where there is aggressive medical tort reform and caps on medical liability judgments? Answer – higher utilization and higher costs, not lower costs as some people would lead you to believe. It makes sense, if there is less risk that a malpractice suit would be filed against you, why not amp up the utilization and make a windfall at the same time? The State of Texas is a very good example of this, but you don’t have to stop there. Look at any State that has aggressive tort reform and you will see higher costs. That’s just the financial toll; there is a human toll as well. There are many patients that have been on the receiving end of a physician that should not have been practicing medicine, but because of aggressive tort reform in some State’s it’s almost impossible to bring a suit.
    Anyhow, there is a great article about the fee for service model called “The Cost Conundrum”. Read it -
    Link: http://www.newyorker.com/reporting/2009/06/01/090601fa_fact_gawande

  4. There are several items that conspire to drive overutilization. Profit motive is probably the most significant, though no physician will admit this. Since physicians are looked upon more favorably by there hospital and physician colleugues if they refer for services and consults more frequently, this also would tend to encourage more utilization as well.
    To discount malpractice, as one commenter has proposed above is undoubtedly false. While following guidelines may help in defense of a lawsuit, they do not prevent all suits from being brought, and this is truley what we seek to avoid. Lawsuits can require time in depositions, time in court, and create more stress on top of loss of confidence. This is what we fear the most since these costs pose financial less since most of us are paid on the basis of what amount of work we do. The primary defense for physicians is, quite frankly, keeping the patient happy. It is more often angry patients who feel their complaints have been dismissed that will seek legal counsel with the thought of suing. When patients come in armed with their internet printouts of how their problem should be diagnosed and handled, it is hard to disuade patients from proceeding with expensive or invasive diagnostic tests. It is far safer to let the insurance company become the bad guy (sorry, your insurance company denied your request for an MRI) since to deny this care risks the patients ire and there is always the rare possibilty that the complaint may have some serious underpinning. We docs live in constant fear of missing the rare but treatable condition, and even if the delay in testing causes no harm to the patient, there may be harm to reputation from the patient who describes his experience to others. To suggest that this fear does not alter our approach to care is not defensible, although I agree it is too often evoked as an excuse.
    MRIs are a good example of a test that has driven costs skyward. Costing anywheres from 500-5000 dollars, they pose no real harm to the patient, so there is no downside to performing these other than cost. The real problem is all the incidental items they find that then become fodder for further testing and potentially more invasive procedures. I try to warn my patients of this slippery slope when they come in asking for MRIs or CTs, but fear of missing that unusaul presentaion of a condition usually takes over, and it usually takes more time to explain carefully all the downsides of excessive scanning.

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