Nearly half of primary care physicians believe that they or their colleagues are over-providing health care to their patients, according to a recent study conducted by Dartmouth Medical School professor Brenda Sirovich published in the Archives of Internal Medicine.
"Physicians are constantly being asked, Did you do enough?' not Did you do too much?'" Sirovich said in an interview with The Dartmouth. "There's a philosophy that you can't go wrong by doing more."
The United States currently spends twice as much on health care per capita than the average industrial nation, and is spending more each year at an unsustainable rate, according to the study, which was published on Sept. 26.
"There's a real debate about whether curbing health care spending means that we're going to have to deprive people of health care that's beneficial or whether there's enough unnecessary care being delivered that we could focus on reducing that," Sirovich said.
Forty-two percent of primary care physicians surveyed believed that patients in their practice were receiving more medical care than necessary, while only 6 percent believed that patients were not receiving enough care, according to the study.
About 25 percent of physicians admitted to practicing more aggressive care such as ordering more diagnostic tests and referrals than they would prefer, and 29 percent believed that other primary care physicians in their community were doing the same, according to the study.
The study identified the trend's major causes as malpractice concerns, clinical performance measures and lack of time spent with patients. Approximately 75 percent of physicians surveyed cited malpractice concerns as a factor leading to more aggressive care. Over 50 percent of physicians surveyed indicated clinical performance measures as a factor, and 40 percent cited an insufficient amount of time to spend with patients.
"We're rarely punished for doing too much, but may well be punished for doing too little," DMS professor Gilbert Welch said in an interview with The Dartmouth.
According to Sirovich, there is an "implicit incentive system that favors a more is better' philosophy."
"Financial incentives are a large part of this story," Welch said. "Not only are the individual doctors often rewarded for doing more, but the institutions [they] work for are rewarded for giving more care. A hospital's survival is dependent on having volume of service."
Of the primary physicians surveyed in the study, 39 percent believe that "other primary care physicians would order fewer diagnostic tests if such tests did not generate extra revenue," according to the study.
Welch suggested that "a more sophisticated reimbursement system" that considers more than just volume of care would be a positive change.
A little under half of physicians estimated that at least one in 10 appointments they have on a typical day could be replaced with a telephone call or e-mail.
"The entire medical system skews more toward procedures than conversations between physicians and patients," said Calvin Chou, a professor of clinical medicine at the University of California, San Francisco.
Chou was invited to comment on the study, and his discussion of the study was published in the Archives of Internal Medicine. Improved communication and closer work with colleagues could decrease malpractice concerns and increase job satisfaction, he said in an interview with The Dartmouth.
The physicians surveyed acknowledged that practice patterns vary across communities, and were curious to see how their practices compared to those of physicians in other areas.
"We interpret this to mean that they are open to feedback and practicing differently and that they want to see things changed," Sirovich said. "If we are going to successfully reform the system, a lot depends on whether physicians are engaged."
Data for the study was collected between June and November of 2009. The study was funded by the Department of Veteran Affairs, according to Sirovich.
