By Nancy Walsh, Staff Writer, MedPage Today
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:
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.