• Primary Care Physicians’ Views on the Health Care System

    I’m constantly telling you what I think of the US health care system, so it only seems fair to talk about what other doctors think of it. There’s a new manuscript out in Archives of Internal Medicine that does just that. A number of researchers surveyed a nationally representative random sample of US primary care physicians (general internal medicine and family practice). They had a 70% response rate, which is really good for mail surveys of physicians, for a sample of 627 docs. They were mostly male (72%), had been practicing for a median of 24 years, and were fairly about evenly split between family medicine (54%) and internal medicine (43%).

    The first set of questions dealt with perceptions of how aggressive care was in their estimation:

    • 42% thought their patients were receiving too much medical care, versus 6% who thought they were receiving too little care (52% thought that care was just right)
    • 28% said they were practicing more aggressively than they would like to be
    • 29% said that other primary care physicians were practicing too aggressively
    • 47% thought that mid-level providers, like nurse practitioners and physician assistants practice too aggressively
    • 61% thought that medical subspecialists practice too aggressively

    Bottom line? They think too much care is being provided, but most of it is coming from mid-level providers or medical subspecialists. When asked why they might be practicing more agressively than they would like to, they gave three main reasons:

    • 76% said malpractice concerns
    • 52% said clinical performance measures
    • 40% said inadequate time with patients

    I wish I could say that I agree with this. I really do. I mean, I trust that the results are accurate, but I don’t think that means we should act on them.

    Why? Well, three-quarters of primary care physicians say that concerns about being sued make them practice more aggressively than they’d like. But research shows that physicians in low malpractice risk areas don’t practice much differently than docs in high malpractice risk areas. They also don’t practice much differently after tort reform passes. You’ve heard me talk about how Texas’ malpractice reform didn’t bring spending down much at all.

    Half blame performance measures, which are intended to help them improve quality. I’m not surprised that lots don’t like them, though; physicians really don’t like being told what to do.

    I sympathize with the last reason. Patient visits are short in the US. But I’m not sure that if they were longer, docs would order fewer tests.

    Notice what’s not in the top reasons? Money. Could it be that doctors might practice more aggressively because when they do, they make more? Well, only 3% believed that financial considerations could influence their own practice. Most, however, thought that other physicians would be affected by such things.

    One of my co-bloggers refers to this sort of thing as “magical thinking”. I call it delusional.

    • “But research shows that physicians in high malpractice risk areas don’t practice much differently than docs in low malpractice risk areas. They also don’t practice much differently after tort reform passes.”

      It’s perception and ingrained habit. In our low crime rural area you can tell who’s move here from the city by how they continue to lock their car doors at every stop. Fear of a lawsuit is very real in civilian medicine. Improving the toxic malpractice climate is a necessary step but it will take time or other measures to reduce all the CYA testing.

      “Money. Could it be that doctors might practice more aggressively because when they do, they make more? Well, only 3% believed that financial considerations could influence their own practice.”

      Most of us don’t own our own CTs or MRIs. Even private practices rarely have x-ray machines or labs anymore. Employed physicians often have these in house but cannot earn extra pay by ordering tests. The unnecessary tests that many of us perceive are either demanded by patients with third party payers or CYA tests.

    • “Research shows that physicians in low malpractice risk areas don’t practice much differently than docs in high malpractice risk areas. They also don’t practice much differently after tort reform passes.”

      Even in tort reform states, the standard is to evaluate physician treatment on “standard of care.” If that’s the case, even a single state with no tort reform could allow plaintiff’s attorneys to claim overtreatment is a “norm” and win that argument in front of an unsophisticated jury.

      Given that’s the case, a physician’s incentives are always to overtest, etc. since the liability risk is not worth the cost. Indeed, that is what I did as a physician and everyone I know as a physician does know.

      Asfor the delusional or magical thinking comments, thats a pretty irrational response to the obvious reality most doctors are pointing out–self-referral laws (i.e., the Stark laws) and the status of many physicians as employees makes it unclear where these mysterious financial incentives appear from for many physicians, including the most egregious overtreaters (ED physicians). You should engage with that argument before making emotional claims on the topic I think…

    • Above, I made an error– know = now

    • Sorry, but when everyone thinks THEY are immune but also thinks everyone else is not – that’s delusional.

    • That is why they call it the invisible hand. People often dont perceive the financial interests that influence them. Since I am president of my group, and deal with the financial issues, docs are more influenced by money than they think. Privately, they will discuss it.

      That said, it is my observation that most docs try to do what is best for their patients. That they do not put money first (though it is still an influence). What we have is a minority of physicians who have become entrepreneurs. They have thoroughly embraced marketing and all available opportunities to make money. These docs usually end up employing other physicians, the kind less interested in making money and just caring for patients. This minority drives an awful lot of spending. Look at the surgicenter near you with flat screen TVs everywhere, fountains and a swimming pool.

      Read the physician throwaways. How often do you see ads for consultants/billing companies that will help to make sure you “dont leave anything on the table”?


    • The physicians explained why they practiced more aggressively than they would like. Were they asked whether THEY personally provided to much care for their patients or was that a more general question?

      I would think that the cost of defensive medicine depends on where you draw the line between prudent care and defensive medicine.. This is both a scientific and moral question,, e.g. do you order an expensive test if there is a one in a thousand chance that not ordering it will lead to a medical problem that while not life threatening forces the person to endure suffering and hospitalization?

      There being nothing remotely resembling a national consensus on this, patients, if they have thought about the issue at all, may come in with widely varying expectations about how their doctors will act.

    • I notice another thing that is the top reasons for that physicians practice too aggressively, the natural bias toward optimism that most people have. That combined with the natural desire to help can lead to trying treatments with below 50% changes of helping.

    • It’s easy for doctors to blame the threat of malpractice suits because it absolves them of blame and Conservatives love to blame patients & lawyers for the cost of health care.

      But one reason besides money (remember many/most doctors are independent businessmen or are partners in groups that own expensive diagnostic tools) is that diagnosis is an art at which some doctors are better than others. So extra tests compensate for lower diagnostic skills. And even the good diagnosticians may order more tests than they think they need either to ensure that they are right or because it can actually be more efficient to get a bunch of tests done at once than to order the most likely first then ask the patient to return for others until a diagnosis is reached.

      The one medical practice I truly deplore is the prescription of antibiotics for people with colds or the flu, not because they will help (they won’t) but because the patients “demand” them. This is inexcusable under the best of circumstances but given the enormous spread of antibiotic resistance during the past decades, the practice should, IMHO, be grounds for censure from medical societies.