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.