The New Health Dialogue

The most recent issue of the Archives of Internal Medicine includes a provocative survey of primary care physicians—one that indicates a significant, long-overdue change in how both providers and patients see medical care.

The study surveyed over 600 physicians by mail, and found that 42 percent believe their patients are getting too much medical care. That’s seven times as many as the six percent who believe their patients aren’t getting enough. Further pressing the case, about 30 percent of PCPs surveyed said that their own practice was more aggressive than they’d like.

Think about what this means. Four years ago, when the Health Policy Program’s director, Shannon Brownlee, published her book Overtreated, most Americans, and a lot of providers, legislators and policy experts thought the only real problem in U.S. healthcare was too little care – because nearly 1 in every 6 Americans was uninsured. Now we have a study that shows that physicians are well aware that overtreatment is also a problem

But before Brownlee breaks out the champagne, it’s worth examinging the somewhat muddled reasons that doctors gave for their habit of delivering unnecessary care. Unsurprisingly, three-quarters of respondents said that malpractice concerns drove them to overtreat patients. That makes sense given the mythology that surrounds malpractice reform in the US—it’s been pushed as a health-cost panacea for years—but it’s simply not borne out by the evidence. Physicians in areas that have already enacted tort reform, as well as those in areas with generally lower financial risk from malpractice, don’t practice all that differently from docs in areas with higher malpractice risks.

The other fascinating-but-unsurprising piece of the study is the results on what physicians think of money’s role in driving their decisions. Only three percent of docs surveyed believed that financial considerations had an effect on their decision-making. When asked about their colleagues, however, a much larger number believed that money played a part. Nearly 40 percent said that other primary care physicians would order fewer diagnostic tests if it were not for the additional revenue; 62 percent believed that specialists over-ordered and over-delivered because of money.

As Aaron Carroll has already commented at the Incidental Economist, such beliefs (“I would never change my practice for money—oh, but my colleagues would!”) are delusional. That’s not using delusional in a derogatory sense. Rather, it’s yet another example of the well-documented “Lake Wobegon Effect,” named after Garrison Keillor’s hometown where “all the children are above average.” People have a strong tendency to rate themselves too highly on everything from nobility of their medical practice habits to their driving skills. We’re not calling doctors liars—we’re saying that they have the same biases as everyone else.

Most importantly, though, this study reflects the fact that doctors and patients are coming to recognize overtreatment for what it is: a pervasive problem with a wide variety of causes. We’re glad the rest of the health policy community has gotten on the overtreatment bandwagon, and we’re looking forward to turning that into new ideas and real change.