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Special Article | Health Care Reform

Too Little? Too Much? Primary Care Physicians' Views on US Health Care:  A Brief Report

Brenda E. Sirovich, MD, MS; Steven Woloshin, MD, MS; Lisa M. Schwartz, MD, MS
Arch Intern Med. 2011;171(17):1582-1585. doi:10.1001/archinternmed.2011.437.
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Background Some believe that a substantial amount of US health care is unnecessary, suggesting that it would be possible to control costs without rationing effective services. The views of primary care physicians—the frontline of health care delivery—are not known.

Methods Between June and December 2009, we conducted a nationally representative mail survey of US primary care physicians (general internal medicine and family practice) randomly selected from the American Medical Association Physician Masterfile (response rate, 70%; n = 627).

Results Forty-two percent of US primary care physicians believe that patients in their own practice are receiving too much care; only 6% said they were receiving too little. The most important factors physicians identified as leading them to practice more aggressively were malpractice concerns (76%), clinical performance measures (52%), and inadequate time to spend with patients (40%). Physicians also believe that financial incentives encourage aggressive practice: 62% said diagnostic testing would be reduced if it did not generate revenue for medical subspecialists (39% for primary care physicians). Almost all physicians (95%) believe that physicians vary in what they would do for identical patients; 76% are interested in learning how aggressive or conservative their own practice style is compared with that of other physicians in their community.

Conclusions Many US primary care physicians believe that their own patients are receiving too much medical care. Malpractice reform, realignment of financial incentives, and more time with patients could remove pressure on physicians to do more than they feel is needed. Physicians are interested in feedback on their practice style, suggesting they may be receptive to change.

Trial Registration clinicaltrials.gov Identifier: NCT00853918

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Figure. Primary care physicians' opinions (n = 627) on the style of medical care practiced in their communities. The most extreme responses (along a 5-point Likert scale) are shaded in white and black; gray shading represents the intermediate responses (eg, “too little” and “too much” for the first question). The neutral category (eg, “just about right”) is omitted from the Figure. Item nonresponse for the 5 questions, in order, was 1.3%, 2.6%, 5.6%, 2.6%, and 2.2%. *No physicians responded “much too little.” NPs indicates nurse practitioners; PAs, physician assistants.

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The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
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Too much health care?
Posted on October 1, 2011
Charles A. Moser, PhD, MD
Sutter Pacific Medical Foundation
Conflict of Interest: None Declared
I had a completely different interpretation of the article by Sirovich et al. suggesting that primary care physicians believe their patients are receiving too much care. First, a majority (52%) thought it was just right and less than 20% would ideally like to practice more conservatively. I am not sure those numbers suggest that our patients are receiving too much care. The authors’ conclusion that financial incentives, malpractice concerns, inadequate time with patients, and clinical performance measures are the cause of this overtreatment is misguided. Would correcting these factors result in “better” care? Second, it is not clear what aggressive medical care these physicians would eliminate (mammograms and pap smears, should we stop checking blood pressures or order screening colonoscopies). What tests do these physicians think are superfluous? Are clinical performance measures helping physicians do the right thing in spite of their instincts? I do not know, but are we ready to abandon them? My last point is to challenge an assumption that I hear all too often. If we practice more cost-effective medicine, somehow there will be enough money to save the U.S. health care system. I agree we need to cut waste out of the system, but most of the costs are not unnecessary tests or even physician reimbursement. Whatever we might save by eliminating “aggressive testing” needs to be balanced with the cost of spending more time with patients (a solution suggested by the authors). Remember there is a shortage of primary care physicians and the more time we spend with patients, the fewer patients can be seen. I am not advocating spending less time with patients or indiscriminate testing, just criticizing overgeneralizations and simplistic solutions. Sirovich, BE, Woloshin, S, Schwartz, LM. Too little? Too much? Primary care physicians' views on US health care. Arch Intern Med.2011;171:1582-1585

Conflict of Interest: Consider this submission to be a letter to the editor for publication.
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