Fear of lawsuits, little time with patients lead to more aggressive care

Ninety-five percent of physicians believe their colleagues differ in their treatments for people with the same condition, a study says.

By Alicia Gallegos — Posted Oct. 10, 2011

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Nearly half of primary care physicians say patients receive too much medical care.

In a study of 627 such physicians, 42% said patients in their practice get too much treatment, and 6% said patients receive too little care. Fifty-two percent of doctors said the amount of care was just right, according to the study published Sept. 26 in Archives of Internal Medicine.

Three in four doctors listed medical liability concerns as the primary reason they practice more aggressive medicine. Forty-percent said inadequate time with patients is a factor in practicing more aggressively.

About one in four physicians practices medicine more aggressively by ordering more tests and making more referrals than they would like to do.

The results are not surprising, said internist Calvin Chou, MD, a professor in the Dept. of Medicine at the University of California, San Francisco, Veterans Affairs Medical Center. He wrote an editorial that accompanied the study.

"I run into problems myself when a patient is very demanding of a particular test that I don't think is particularly warranted," Dr. Chou said. "I think I'm pretty good at discussing it with them, but I know that I'm not perfect. There are times when it's easier to order the test than have a discussion."

Seventy-six percent of surveyed physicians are interested in learning how aggressive or conservative their practice style is compared with other physicians in their community. Ninety-five percent believe doctors differ in their treatments for patients with the same condition.

Financial incentives influenced aggressive practices, the study showed. Six in 10 doctors said diagnostic testing would decrease if it did not generate revenue for medical subspecialists. Thirty-nine percent said diagnostic testing would decline if it did not generate revenue for primary care physicians.

Trying to prevent lawsuits

The study shows how various factors, such as preventing lawsuits, seem to favor more aggressive medical care, said internist Brenda Sirovich, MD, a study co-author and staff physician for the Outcomes Group at the VA Medical Center in Vermont. She is also an associate professor of community and family medicine at the Dartmouth Institute for Health Policy and Clinical Practice.

"There are a lot of built-in external factors that are sending the message that more is better," she said. "Physicians recognize that that is not necessarily right."

Dr. Sirovich hopes the study will compel the medical community and others to examine external factors, such as clinical guidelines, and create a better national dialogue on how to change perceptions that more care always means better care.

In his editorial, Dr. Chou noted potential approaches to reducing aggressive care by doctors. Better communication with patients has been proven to enhance the doctor-patient relationship and positively impact patient outcomes, he said. He also said doctors should be mindful of patients' feelings and experiences during patient encounters.

"If we can slow down and be more mindful of our practice and really make certain we're not just checking off lists, [this] not only will make doctors feel more in control, but happier in their practices," he said.

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Too much care?

View in PDF

Click to see data in PDF.

A study asked primary care physicians how each of the following factors impacts their ordering of diagnostic tests and patient referrals. Doctors listed medical liability concerns, clinical performance measures and inadequate time with patients as top reasons for providing more medical care.

Factor Leads me to do less Has no effect Leads me to do more
Liability concerns 0.3% 23.8% 75.9%
Clinical reminders or performance measures 2.9% 44.8% 52.3%
Inadequate time to spend with patients 8.3% 51.5% 40.3%
Hassle of communicating with a patient's other physicians 7.1% 78.7% 14.2%
Financial security 0.5% 92.7% 6.8%
Financial expectations from practice or hospital system 3.4% 90.9% 5.7%
Insurance or institutional constraints (pre-approval) 48.7% 47.4% 3.9%

Source: "Too Little? Too Much? Primary Care Physicians' Views on US Health Care," Archives of Internal Medicine, Sept. 26 (link)

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External links

"Too Little? Too Much? Primary Care Physicians' Views on US Health Care," Archives of Internal Medicine, Sept. 26 (link)

"Nice work if you can get it: Comment on 'Too Little? Too Much? Primary Care Physicians' Views on US Health Care,' " Archives of Internal Medicine, Sept. 26 (link)

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