A survey of US primary care physicians shows that many believe that their own patients are receiving too much medical care and many feel that malpractice reform, realignment of financial incentives and having more time with patients could reduce pressures on physicians to do more than they feel is needed, according to a report in the September 26 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.
"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," the authors write as background information in the article. "A number of health care epidemiologists and economists, however, have suggested that a substantial amount of U.S. health care is actually unnecessary." The authors also note that the opinions on rate of care of primary care physicians, whom they acknowledge are the "frontline of health care delivery," are unknown.
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., conducted a national mail survey of U.S. primary care physicians identified from a random sample of the American Medical Association Physician Masterfile, between June and December 2009. Of the surveys mailed, 627 physicians participated, for a response rate of 70 percent.
Nearly half (42 percent) of all survey respondents believe that patients in their own practice receive too much medical care, while only 6 percent believe that their patients receive too little care. Just over half (52 percent) believe the amount of care received is just right. Additionally, 28 percent of respondents said they personally were practicing more aggressively than they would like, and 29 percent felt that other primary care physicians in their community were practicing too aggressively.
Forty-seven percent of respondents reported that mid-level primary care clinicians (nurse practitioners, physician assistants) practice too aggressively, and 61 percent felt that medical subspecialists practice too aggressively. Almost all physicians in the survey (95 percent) believe that primary care physicians vary in their testing and treatment of patients, and most (76 percent) were interested in learning how their own practice compared to those of other physicians.
Study participants identified three factors they believe cause physicians to practice too aggressively: malpractice concerns (76 percent), clinical performance measures (52 percent) and inadequate time to spend with patients (40 percent). Eighty-three percent of physicians felt they could easily be sued for failing to order a test that was indicated, while 21 percent felt that they could be sued for ordering a test that was not indicated.
The authors conclude that their results show that, "physicians are open to practicing more conservatively." They also note that, "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."
Invited Commentary: Nice Work if You Can Get It
In an invited commentary, Calvin Chou, M.D., Ph.D., from the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, discusses the results of the survey conducted by Sirovich et al saying, "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 a solution to overly aggressive practicing writing, "Perhaps there are two specific approaches that primary care physicians can use to decrease aggressive practices: communication and avoidance of burnout." Communication is important to patients, he notes, 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."
Additionally, Chou notes 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 writing 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," Chou concludes. "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."
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