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Patient care may be suffering from too much, too soon

When it comes to medical care, patients aren’t getting too little, too late, but too much, too soon, according to many primary care physicians (PCPs).

A recent survey of PCPs found that many believe they often provide more care than is really needed, and that malpractice reform, realignment of financial incentives, and having more time with patients could relieve some of that pressure. For the report, published recently in the Archives of Internal Medicine, Brenda E. Sirovich, MD, MS, and colleagues from the VA Outcomes Group, White River Junction, Vermont., and the Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire, mailed surveys to U.S. PCPs from a random sample of the American Medical Association Physician Masterfile between June and December 2009. Responses were received from 70% (627), with 42% saying they believe that patients in their own practice receive too much medical care. Only 6% of the respondents thought patients received too little care, with the remainder saying the amount of care is just right.

In addition, 28% of participants said they were practicing more aggressively than they would like, whereas an almost equal number, 29%, said that other PCPs in their community were practicing too aggressively.

PCPs did not think they were the worst offenders when it came to excessive treatment, however. Mid-level providers—nurse practitioners and physician assistants—over-treat patients, according to 47% of the survey respondents, and 61% suggested that medical subspecialists practice too aggressively.

Most of the PCPs responding to the survey (76%) said they were interested in finding out how their practices, and level of care provided, compared with other practices.

Three key drivers pushed physicians to practice too aggressively, according to respondents. Those include malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). For example, failure to order a test that was indicated could get them sued, 83% of the respondents said, and 21% expressed fear that they could be sued for ordering a test that was not indicated.

The authors concluded that "physicians believe they are paid to do more and exposed to legal punishment if they do less. Reimbursement systems should encourage longer [PCP] visits and telephone, e-mail, and nursing follow-up, rather than diagnostic intensity." On the other hand, they said, PCPs are open to practicing more conservatively if given a chance.

In an invited commentary, Calvin Chou, MD, PhD, from the University of California, San Francisco, and San Francisco Veterans Affairs Medical Center, said PCPs are demonstrating “a kind of trained helplessness,” saying that “physicians know they are practicing aggressively but feel they have no recourse.”

He suggested that PCPs try to improve the quality of communication with patients while also taking steps to avoid burnout. He also recommended a change in medical school curriculum to train “[PCPs] in mindfulness, communication, and self-awareness showed decreased burnout, improved well-being scores, and increased capacity in relating with patients."

This study was supported by the U.S. Department of Veterans Affairs and, in part, by the National Institute on Aging.

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