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Study Finds Many Primary Care Physicians Think They Provide Too Much Care
"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."
- A new study finds that many primary care physicians, including family physicians, think their patients are receiving too much medical care.
- More than 28 percent of primary care physicians said they themselves were practicing medicine more aggressively than they wanted to.
- The three reasons why physicians think they are practicing too aggressively are malpractice concerns, having to meet clinical performance measures and not having enough time with patients.
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."
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:
- malpractice concerns (76 percent),
- having to meet clinical performance measures (52 percent) and
- not having enough time with patients (40 percent).
"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.
Not Enough Time
"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."