If a physician has too little time, the quickest way to get the patient out of the exam room is to make a referral. This is a problem that could get worse when health care reform introduces new patients to the system.
Doctor, Your Patient Will See You Now
The concept of too much might change depending on who you ask. But as far as primary care physicians are concerned, 42% believe that patients in their own medical practice receive too much care (Arch. Intern Med. 2011;171(17)). Steven Kussin, MD, author of (Rowman & Littlefield), is not surprised by the results.
“I think between defensive medicine, profit motive, fee for service and frustration over a dropping fee schedule, physicians overcompensate by ordering [tests and lab work] to stabilize their income,” Kussin said. “That’s considered over-treatment.”
Fear of malpractice
According to the survey results, 76% of physicians identified malpractice concerns as the main reason leading them to practice more aggressively. This reaction is what Kussin labels defensive medicine.
“Defensive medicine means that no doctor is ever sued for doing too much,” Kussin explains. “But they are sued for the perception that they’ve done too little. And therefore all the incentives are to do more rather than less, because a thick chart is like thick body armor. It’s harder to get hurt.”
But Kussin, whose clinical career ended in 2007 following a traumatic car accident, sparking his passion for patient advocacy, understands the leaning toward defensive medicine. He explains that being sued is “psychologically traumatic, disruptive to a practice and disruptive to family life. The implications in court are so horrifying to experience.”
If the fear of a medical malpractice lawsuit isn’t enough, Kussin says another important factor leading to over-treatment is the public expectation of the level of treatment physicians should provide.
When the U.S. task force stated that mammograms in women age 40 to 49 were not necessary, the hue and cry, including in Congress, had absolutely nothing to do with the medicine and everything to do with the politics. Kussin says. As such, the opportunity for physicians to use that recommendation as a way of not doing mammograms, or at least recommending that women not have them, was lost forever.
“The public demands mammograms, just as men demand PSAs,” Kussin says. “They’ve been scared. And so doctors not only respond out of the fear of malpractice suits — not only because they’re paid more when they do more — but because the public asks for more.”
According to the survey, 40% of physicians indicated that inadequate time to spend with patients leads them to practice more aggressively. Or as Kussin points out, if a physician has too little time, the quickest way to get the patient out of the exam room is to make a referral. The physician rationalizes that if he or she doesn’t have the time, then there are specialists who do, so it’s better to spend the patient there.
“The poor amount of time that patients get with their physicians is indeed a very strong reason why there’s over-diagnosis, which leads to over-treatment,” Kussin says. “And that’s not going to change. The doctors don’t have the time, or the space, or the resources to really put in front of patients answers to their problems, offering them the full spectrum of alternatives that exist.”
The problem could rapidly get worse. Kussin says that health care reform will result in an influx of new patients — patients with a long, pent-up demand for health care services — that, combined with a projected physician shortage, will overwhelm the health care system.
The solution, or part of the solution, he says, is shared decision centers, and Kussin runs one. Patients can look at decision aids, which are created according to an international standard to make them as unbiased and evidence based as possible.
“And if there’s no science, then there’s a reasonable back and forth discussion regarding to do, or not to do, and risks versus benefits,” Kussin says. “So patients have a better idea of what’s going on.”
These centers are helpful because, according to Kussin, a patient’s priorities aren’t typically discussed during visits to the doctor’s office. Over time these priorities will change, which also needs to be addressed.
Shared decision centers are still rare in this country, but Kussin believes they can put a positive dent in the over-diagnosis and over-treatment problem.
“Because patients, if given the choice, and opportunity to weigh in, will make decisions that eliminate all the over-diagnosis and then over-therapy that follows,” Kussin says.