One afternoon when I was running later than usual, I recognized a familiar face among the patients waiting to see me. A voluble newspaper fanatic, the gentleman, in his 70s, was usually eager to discuss the latest headlines with me. That day, however, he was remarkably quiet. He was suffering from the flu. “I’m really feeling no good,” he rasped.
After hearing about his symptoms and examining him, I suggested fluids, rest and maybe a cough suppressant and nasal decongestant. I saw the corners of his eyes and mouth fall. I understood.
He was waiting for me to offer him a prescription, or to order more tests.
I knew that he didn’t really need blood drawn or a chest X-ray, and he certainly didn’t need antibiotics for the virus that was causing his symptoms. But I also knew what would happen if I took the time to explain why and to answer all the questions that would no doubt follow: irritated looks from other patients, the staff or even my colleagues because of the time I spent with one patient.
Offering unnecessary care would, in fact, be faster.
Later, when I bumped into a senior colleague and explained my quandary, he simply shrugged. “In training, the most important lesson they teach you is when not to do something,” he said. “But in real life, it’s all about staying out of trouble and surviving.
“Even if that means ordering things you might not think necessary,” he added with a wink.
I recalled my colleague’s words this week when I read a study about the excessive and unnecessary care patients receive and how their doctors feel about it.
For several decades now, researchers have pointed to excessive care as an important factor behind spiraling health care costs. Some studies have estimated that up to 30 percent of the care delivered to patients in the United States is unnecessary, and sometimes even harmful. More and more policy makers and insurers have been addressing the overuse problem like a calorie-reduction plan to lose weight, arguing that eliminating excess from our medical diet is critical to streamlining our corpulent health care system.
But as anyone who has ever tried to shed pounds knows, deciding to cut extra calories is one thing. What happens at the table is an entirely different matter.
This week’s Archives of Internal Medicine offers a glimpse of what happens at one “table” of health care: the primary care doctor’s office. Researchers analyzed more than 600 responses to a nationwide mail survey that went out to primary care doctors and found that nearly half of them believed that patients in their practice were receiving too much care. Almost a third acknowledged that it wasn’t just other providers at fault; it was also their own way of providing care.
“Doctors aren’t oblivious to what is going on,” said Dr. Brenda Sirovich, the lead author and an associate professor of medicine in the Outcomes Group at the White River Junction Veterans Affairs Medical Center in Vermont and at the Dartmouth Institute for Health Policy and Clinical Practice. “They recognize that something is wrong.”
The doctors surveyed attributed the pressure to overtreat patients primarily to three factors. Almost half believed that inadequate time allotted to patients led them to order more tests or refer to specialists. More than three-quarters also believed that the fear of being sued or perceived as not doing enough put undue pressure on them to order more. A doctor might, for example, order an unnecessary CT scan for a patient who had only a minor forehead bruise from a fall but a perfect neurologic exam.
Most notably, more than half the doctors believed that the current quality measures and clinical guidelines endorsed by health care experts and insurers as a way to rein in excesses were in fact having the opposite effect. The guidelines might, for example, require that patients with high blood pressure and diabetes have a specific blood test every three months and take high blood pressure medications as soon as their blood pressure exceeds 140. Because insurers are increasingly linking payment to these guidelines, physicians must strictly follow the quality measures to be paid, regardless of the patient’s specific situation. Ironically, most of these quality measures are based on, well, more testing and treatments.
“Guidelines in general set a bar for not enough care,” Dr. Sirovich said. “There aren’t any guidelines that set a bar for too much care.”
Others have proposed that doctors might prescribe unnecessary care for financial gain, but only 3 percent of doctors in this study believed their decisions were based on a desire to generate extra revenue. Dr. Calvin Chou, author of an editorial accompanying the study and a professor of medicine at the University of California, San Francisco, and the San Francisco Veterans Affairs Medical Center, believes that overtreating patients stems not from an active desire to do or gain something, but rather from a sense of overwhelming helplessness.
“Many doctors feel like they are on a treadmill and are running scared because of malpractice and having to check off all the checkboxes of quality measures,” Dr. Chou said. “They feel like they are in an oppressive situation that they can’t do anything about.”
Nonetheless, there was evidence that doctors were not resigned to their professional plight. Seventy percent of the physicians took the time to answer and return the mailed survey, in part, Dr. Sirovich believes, because “doctors are interested and want to talk about these issues.” Moreover, a majority of doctors surveyed acknowledged being curious about how their colleagues practiced; and well over half asked to see a report the researchers offered on how practices in their own communities differed from others. All of this “suggests that doctors are open not only to changes in their own practices, but also to working together to realign the incentives of the system,” Dr. Sirovich said.
She added: “It all comes down to doctors and patients sitting in the office and deciding what to do. We are not going to be successful in reducing unnecessary care until physicians are also engaged.”
