Primary Care Docs Feel Pressure to Do More Tests

Sept. 27, 2011— -- Primary care physicians in the U.S. say they feel forced to provide excessive care to their patients, particularly in terms of testing and referrals, a national survey found.

A total of 42 percent of primary care physicians acknowledged a belief that their patients were receiving more medical care than they needed, according to Dr. Brenda E. Sirovich 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: Concerns about malpractice; increasing reliance on clinical performance measures; and inadequate time with patients.

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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 percent expressed concerns that their patients were not receiving enough care.

Forty-seven percent indicated that physician assistants and nurse practitioners practiced more aggressively than primary care physicians, and 61 percent said subspecialists also were more aggressive.

Forty-five percent of physicians believed one in ten patients 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 percent 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 percent 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," Sirovich and colleagues reported.

Although a very small minority (3 percent) of physicians admitted that financial benefits influenced their aggressiveness in practice, 39 percent 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 percent 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.

"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," the authors stated.

Limitations of the study included its 70% response rate and the relatively simple "too much or too little care" approach used in the survey.

In an invited commentary accompanying the study, Dr. Calvin Chou of the University of California San Francisco, noted that overly aggressive practice patterns can be curbed with increased "patient-centered communication" and clinician "mindfulness." The latter is defined as "a purposeful, nonjudgmental ability to notice and observe occurrences in the moment, to decrease reactivity to difficult situations, and to initiate action with awareness and intention."

"Having mindful and effectively communicative physicians in a system of care that supports a common vision for quality will be hard work, but we can get it if we try," Chou wrote.