Primary Care Docs Feel Pressure to Do More Tests
By Nancy Walsh, Staff Writer, MedPage Today
Published: September 27, 2011
Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and
Dorothy Caputo, MA, RN, BC-ADM, CDE, Nurse Planner
Primary care physicians in the U.S. believe they are being forced to provide excessive care to their patients, particularly in terms of testing and referrals, a national survey found.
A total of 42% of primary care physicians acknowledged a belief that their patients were receiving more medical care than they needed, according to Brenda E. Sirovich, MD, of the Veterans Affairs Outcomes Group in White River Junction, Vt., and colleagues.
Writing in the September 26 Archives of Internal Medicine, the researchers reported that there were three main reasons why clinicians felt they had to practice aggressively:
•Concerns about malpractice, 76%
•Increasing reliance on clinical performance measures, 52%
•Inadequate time with patients, 40%
Action Points
■Explain that primary care physicians in the U.S. believe they are being forced to provide excessive care to their patients, particularly in terms of testing and referrals.
■Point out that according to the survey results, the most common reason why primary care physicians said they felt they needed to practice aggressively was concern about malpractice.
In the ongoing debate about healthcare reform -- with some arguing that the outsized national price tag for healthcare is unsustainable and others raising the specter of rationing -- the voices of primary care physicians have been largely unheard.
Yet it is primary care physicians who are in the unique situation of being able to direct and control the types of costly care that patients are given.
To explore these physicians' experiences and beliefs, Sirovich and colleagues surveyed 627 family physicians and internists, the majority of whom were male and had been in practice for almost 25 years.
Only 6% expressed concerns that their patients were not receiving enough care.
A total of 47% indicated that physician assistants and nurse practitioners practiced more aggressively than primary care physicians, and 61% said subspecialists also were more aggressive (P<0.001 for both).
Another finding was that 45% of the physicians believed that 10% of patients seen on any given day could be adequately dealt with by a phone call, through email, or by a nurse or other personnel.
Concerns about malpractice were reflected in the numbers, with 83% expressing a belief that a lawsuit could result if they did not order a test that was indicated for a given clinical situation, while just over 20% felt they might be sued if they ordered an unnecessary test.
"The extent to which fear of malpractice leads to more aggressive practice (so-called defensive medicine) has been hotly debated; based on our findings, we believe it is not a small effect," observed Sirovich and colleagues.
Although a very small minority (3%) of physicians admitted that financial benefits influenced their aggressiveness in practice, 39% said that other primary care physicians would be likely to cut back on testing if there was no financial gain.
They also estimated that 62% of subspecialists would perform fewer diagnostic tests if there was not extra revenue associated with doing so.
As to the effect of clinical performance measures, they suggested that "uncritical adherence" could undermine care by encouraging the use of interventions unlikely to be of benefit.
They cautioned that considerable change will be needed for physicians to begin practicing more conservatively.
"There needs to be a fundamental realignment of financial incentives and reform of the malpractice system. Physicians believe they are paid to do more and exposed to legal punishment if they do less," the authors stated.
Limitations of the study included its 70% response rate and the relatively simple "too much or too little care" approach used in the survey.
In an invited commentary accompanying the study, Calvin Chou, MD, PhD, of the University of California San Francisco, noted that overly aggressive practice patterns can be curbed with increased "patient-centered communication" and clinician "mindfulness."
The latter is defined as "a purposeful, nonjudgmental ability to notice and observe occurrences in the moment, to decrease reactivity to difficult situations, and to initiate action with awareness and intention."
"Having mindful and effectively communicative physicians in a system of care that supports a common vision for quality will be hard work, but we can get it if we try," Chou wrote.
The study was funded by a Veterans Affairs Merit Review grant and by the National Institute of Aging.
The authors had no financial disclosures.
This article was developed in collaboration with ABC News.
Primary source: Archives of Internal Medicine
Source reference:
Sirovich B, et al "Too little? Too much? Primary care physicians' views on US health care" Arch Intern Med 2011; 171: 1582-1585.
Additional source: Archives of Internal Medicine
Source reference:
Chou C "Nice work if you can get it" Arch Intern Med 2011; 171: 1585-1586. View Comments By: Healthcare Professionals All
Betty C. Jung, RN, MPH - Sep 28, 2011
Well, this supports the whole trend of why future physicians are not going into primary care, and how undervalued primary care practitioners are regarding their role in providing good medical care.
Because the health care system is so fractured and in disarray, the worst thing that can happen to a patient is not having a good primary care physician who can help navigate the system with them.
At least ONE physician should know what is going on with the patient at all times. This is a major problem with the way things are now - too many cooks spoiling the broth.
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