Study Finds Many Primary Care Physicians Think They Provide Too Much Care

Nearly half of the nation's primary care physicians think their patients are receiving too much medical care; only 6 percent think patients are receiving too little care. That's according to a recent study conducted by researchers at Dartmouth Medical School in Hanover, N.H., and the Dartmouth Institute for Health Policy and Clinical Practice and published in the Archives of Internal Medicine.

The study (abstract), which was based on a nationwide survey of 627 family and general internal medicine physicians, found that 42 percent of those surveyed thought their patients were receiving too much care. In addition, many respondents indicated that financial incentives encourage aggressive practice, and a large majority (76 percent) would like to know how their approach to treatment compares with that of their peers in their community.

"Some might find it surprising that physicians thought their own patients were getting too much care since, theoretically, physicians have some level of oversight over the amount of care patients receive," said Brenda Sirovich, M.D., M.S., lead author of the study and an associate professor of medicine and of community and family medicine at Dartmouth Medical School.

This finding is particularly relevant because primary care physicians are one of the keys to reducing and eliminating waste in the nation's health care system, said Sirovich, who also is a general internist with the Outcomes Group at the Veterans Administration Medical Center in White River Junction, Vt. "We interpret this to mean that primary care physicians think there's a problem -- almost half think their own patients are getting too much care," said Sirovich. "This is important, because successful reform of the system to reduce unnecessary care depends on physicians being engaged."

Sirovich said that this is the first time physicians, as a group, have been asked about the amount of health care they provide. "I think we are all aware of how much we spend as a country on health care," she told AAFP News Now. "I would say it is widely recognized that this (level of spending) is not sustainable."

However, there is real debate about whether addressing the issue of health care spending will lead to depriving people of beneficial care and, ultimately, to health care rationing, Sirovich said. In addition, there are questions about how to identify and eliminate waste in the system.

"We wanted to ask practicing primary care physicians what they thought," said Sirovich. "They are the front lines of the health care system and oversee most of the health care that patients receive, so we thought they would have a pretty good perspective in answering that question."

The survey also found that 28 percent of primary care physicians said they were practicing medicine more aggressively than they wanted to. This figure is nearly identical to the proportion of respondents (29 percent) who said they believed other primary care physicians in the community were practicing too aggressively. The survey defined aggressive care as ordering more tests or making more referrals, said Sirovich.

In addition, nearly 50 percent of the physicians surveyed said nurse practitioners and physician assistants were practicing too aggressively, and 61 percent believed subspecialists were practicing too aggressively.

Survey respondents gave three main reasons why they might be practicing more aggressively:

"The extent to which fear of malpractice leads to more aggressive practice (so-called defensive medicine) has been hotly debated," said the study. "Based on our findings, we believe it is not a small effect. Estimates that have relied on differences in malpractice risk across communities ignore the likelihood that the pervasive threat of litigation leads all physicians to practice more aggressively -- to an extent that is not easily predictable."

"Primary care docs overwhelmingly think they could easily be sued for doing too little -- that is, failing to order a test that was indicated. But few believe they could end up being sued for doing too much -- that is, ordering an unnecessary test," said Sirovich.

Inadequate time with patients also may play a role in driving aggressive treatment by prompting physicians to turn to tests and referrals when there is not enough time to spend with patients, according to the study. In addition, "The proliferation of clinical performance measures may encourage utilization -- and, paradoxically, lower quality of care -- by promoting uncritical adherence to interventions of increasingly tiny benefit."

"I think measuring performance is a good thing," said Sirovich. But nearly all performance measures establish a bar of "Are you doing enough for your patient?" she said. "That is implicitly saying, 'You can't err on the other side.'"

In the final analysis, the study noted that the findings suggest physicians are open to practicing more conservatively. At the same time, however, if physicians are to change their practice behaviors, a lot will have to happen. "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," said the authors.

The study also calls for payment systems that "encourage longer primary care physician visits and telephone, e-mail, and nursing follow-up, rather than diagnostic intensity." In addition, said the authors, "Caution is warranted for policy solutions that promote increased reliance on midlevel primary care providers and clinical performance measures -- efforts that may ironically increase utilization."