Patients Get Too Much Medical Care, Doctors Say

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Patients get too much medical care, doctors say - Vital Signs - MarketWatch

Patients get too much medical care, doctors say , 28% of doctors say they overtreat their patients


SAN FRANCISCO (MarketWatch) — Primary-care doctors are in many ways the gatekeepers of the U.S. health-care system. So what does it mean when more than one in four of them say they may be guilty of overtreating their own patients?
Twenty-eight percent of physicians polled said they personally were practicing more aggressively than they would like, and 29% said they believed their local peers were doing so, according to a survey of 627 family-practice and internal-medicine doctors published in the Sept. 26 edition of the Archives of Internal Medicine.


Fear of being sued figured prominently in the causes they cited, with more than three out of four primary-care doctors saying malpractice concerns lead them to order more diagnostic tests or referrals than might be necessary.
“Physicians overwhelmingly think they could be sued for not doing something, but very few think they could be sued for doing something excessive or unnecessary,” said Dr. Brenda Sirovich, the study’s lead author and a staff physician at the Veterans Affairs Medical Center in White River Junction, Vt.
Another 40% of primary-care doctors said they erred on the side of too much care because they didn’t have adequate time to spend with their patients. And more than half said complying with clinical performance measures influenced them to do more, the study found. Such measures are designed to improve patient care but may subtly nudge doctors toward the more aggressive side of the continuum when such a move isn’t necessary, Sirovich said.


“Almost all of those types of measures by which physicians or health-care practitioners are rated or judged measure a bar that says ‘Is there enough care?’ Almost none of those measures are asking ‘Are you doing too much?’” she said. “It’s another one of those things where we’re either intentionally or unintentionally pushing toward the more-care-is-better-care side of the equation. What we’re seeing from these findings is physicians sense that.”
More than half of U.S. primary-care physicians, or 52%, said they believe their patients are receiving appropriate amounts of health care. But 42% said they believe patients in their own practices are getting too much care compared with only 6% who said their patients were receiving too little care.
Doctors also acknowledged that financial incentives from the fee-for-service payment model encouraged them to do more rather than less. Thirty-nine percent said other primary-care doctors would order fewer diagnostic tests if those tests didn’t generate extra revenue for them, and 62% said medical subspecialists would cut back if the tests didn’t come with financial incentives.
Doctors eager for answers

Perhaps the most hopeful finding of the survey: More than three out of four primary-care doctors are interested in getting feedback on their practice style to see where they fall on the spectrum of conservative to aggressive care.
That suggests physicians are receptive to addressing the problem of overtreatment, Sirovich said.
“We’ll probably have buy-in from doctors,” Sirovich said. “That’s important because if physicians aren’t engaged in these efforts then they’re less likely to succeed.”
In the national quest to raise health-care quality while also controlling spiraling costs, many doctors and policymakers are trying to ensure that patients receive the right care at the right time every time. But developing evidence-based treatment standards for different conditions and for patients who face multiple complex diagnoses can be a moving target due to changing scientific findings, and many experts agree there’s wide variation in how doctors and hospitals address the same medical issues.
As a result, patients are sometimes left to feel like they’ve entered the legal system instead of the medical system when a doctor orders a slew of tests in an apparent attempt to rule out diseases with only a remote possibility of being the cause of the problem.

The practice of such defensive medicine has led to concern that overtreatment does more harm than good. Patients unnecessarily sent for CT scans, for example, may be exposed to excess radiation that can raise their cumulative lifetime risk for cancer. Those sent for other tests may suffer undue anxiety and incur extra costs and health risks as the uncertainty leads to a cascade of medical interventions of dubious value.
“We kind of want to cover our behinds in a way, but most of the time that kind of thinking is counterproductive,” said Dr. Calvin Chou, a professor of medicine at the University of California-San Francisco and a doctor at the Veterans Affairs Medical Center in San Francisco. Chou wrote a commentary on the study in the Archives of Internal Medicine.
The force of habit drives many doctors to make mental to-do lists of all the possible things that could be afflicting a patient and all the tools at their disposal to form a diagnosis, he said.
Doctor’s advice to doctors: slow down

“Many have gotten burned in the past by not thinking of something, so something that is low probability may sneak in on the list. I think doctors run scared thinking they may get sued or miss something,” he said.
“It’s true we definitely need to rule out a heart attack or a thing that’s going to kill the patient first. But if that means a whole bunch of invasive tests, we have to stop and think about whether that’s the right thing to do.”
Chou advised doctors to slow down, be mindful and focus on improving their communication skills with their patients.
“Communication has always been viewed in the medical profession as something no one really needed to work on, and just by virtue of going to medical school you had good communication skills,” he said. “We now know that’s not true, and that good communication skills lead to better patient outcomes and poorer communication skills lead to more malpractice suits. And we know that communication skills can be taught.”
Preventing burn-out is another big factor, Chou said, and medical practices large and small need to help doctors with what he admits isn't an easy prescription. “If a system in which a doctor practices does not support that kind of training or that kind of culture, then it’s not enough.”
For their part, patients should come to their office visits prepared with a list of questions and speak up if they think the doctor isn’t listening to their concerns, Chou said.
“It’s hard for a patient to say to their doctor ‘I feel like I’m not communicating with you well,’” he said, noting that such an assertion can balance the power equation. “Personally, I always greatly appreciate it when they bring that to my attention rather than just picking up and leaving. Then I never know what happened.”
 

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