According to an investigation in the September 26 issue of Archives of internal Medicine, one of the JAMA/Archives journals, results from a survey of primary care physicians in the U.S. have revealed that several physicians believe their own patients are receiving too much medical care, and several believe that malpractice reform, realignment of financial incentives and more time with their patients might reduce pressure on them to do more than they consider needed.
The researchers explain: "Per capita U.S. health care spending exceeds, by a factor of two, that of the average industrialized nation and is growing at an unsustainable rate. A number of health care epidemiologists and economists, however, have suggested that a substantial amount of U.S. health care is actually unnecessary." They also state that the opinions on rate of care of primary care physicians, whom they acknowledge are the "frontline of health care delivery," are unknown.
Between June and December 2009, Brenda E. Sirovich, M.D., M.S., and colleagues from the VA Outcomes Group, White River Junction, Vt., and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, N.H., carried out a national mail survey of U.S. primary care physicians identified from a random sample of the American Medical Association Physician Masterfile, 627 physicians participated in the survey, making up a response rate of 70%.
Almost half (42%) of physicians who responded to the survey thought that their own patients received too much medical care, while only 6% of physicians thought their patients received too little. 52% of physicians believed the amount of care patients received is appropriate. Furthermore, 28% of physicians who responded said they personally were practicing more aggressively than they would like, and 29% of physicians believed that other physicians in their community were practicing too aggressively.
47% of those who participated in the survey reported that mid-level primary clare clinicians (nurse practitioners, physician assistants) practice too aggressively, and 61% believed that medical subspecialists practice too aggressively. Nearly all those who participated in the survey (95%) thought that primary care physicians differ in their testing and treatment of patients, and the majority (76%) were interested in how other physicians practice compares to their own.
Three factors were identified by the participants for what they felt might cause physicians to practice too aggressively:
- Malpractice concerns (76%)
- Clinical performance measures (52%)
- Inadequate time to spend with patients (40%)
"physicians are open to practicing more conservatively. Physicians believe they are paid to do more and exposed to legal punishment if they do less. Reimbursement systems should encourage longer primary care physician visits and telephone, e-mail and nursing follow-up, rather than diagnostic intensity."
In an invited commentary, Calvin Chou, M.D., Ph.D., from the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, talks about the results of the survey carried out by Sirovich, explaining: "implicit in these findings is a kind of trained helplessness - it seems that physicians know they are practicing aggressively but feel they have no recourse."
Dr. Chou offers an answer to overly aggressive practicing saying that: "perhaps there are two specific approaches that primary care physicians can use to decrease aggressive practices: communication and avoidance of burnout." He explains that communication is crucial to patients because "instead of measuring effective diagnosis and treatment outcomes, patients tend to define quality of care in terms of the quality of communication with members of their health care team." He continues that "mindfulness" (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") can increase communication and decrease burnout saying that, "a curriculum that trained primary care physicians in mindfulness, communication and self-awareness showed decreased burnout, improved well-being scores and increased capacity in relating with patients."
"In today's high-paced care delivery system, we cannot afford to spend more resources supporting the status quo. 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."
Written by Grace Rattue