Doctors’ practice patterns are more complex and amorphous animals than fear of litigation. They’re influenced by training, experience, competence, geography (including costs), greed, and government oversight. Yes, even honest physicians, if they are honest, have to admit financial incentives are a motivating factor. It shouldn’t be forgotten that the practice of medicine is a business as well as a calling. If it fails as the former, we all lose the latter. It takes many years and sleepless nights to make a doctor. What is fair or unfair compensation I’ll leave to the individual observer.

Experience affects practice patterns. Physicians just out of training, by definition, have less of it. Hence, they are less likely to rely on their history, physical exam, and judgment than on testing and technology, when compared to their more experienced colleagues. This is just the nature of the learning process. However, it seems to me that the way newer physicians are trained, there is more of an emphasis on this style of practice. An example: A young emergency room physician calls regarding a patient with chest pain of days’ duration that, by history, virtually excludes a cardiac event as the diagnosis. After telephone consultation with an offsite specialist (which costs nothing except risk for the specialist) he is still reluctant to discharge the patient. So the specialist asks if a normal echocardiogram (an ultrasound study of the heart) would provide the evidence he needs to send the patient home. The answer is yes, and another hospital charge is born. An in-person heart consultation would have also generated fees. Now, the emergency physician in this vignette was inexperienced, as we all are at the beginning of our careers, but not necessarily incompetent. Incompetence, with or without inexperience, also drains our resources. Fortunately, in my experience, the number of incompetent doctors is very small, a testament to the high standards in place for medical school entry and the rigorous and long years of training. (I hope this doesn’t change; some colleagues are beginning to complain that the shorter work hours now mandated for interns and residents in training are reducing “out of the box” experience and the quality of health care. On the other hand, a younger associate reminds me “There is no learning after 3 a.m.”).

Geography influences practice patterns. The extent to which is reflects reimbursement rates and “culture” is unclear. Reimbursement, which varies dramatically by location, is in part dictated by costs of living and doing business, and in part by historical precedent and politics. (A “rural” designation such as in the area where I practice has much lower reimbursement than say, a city like in Los Angeles or San Francisco.) In this economic climate the imbalance is not likely to change for a sparsely populated region with lots of good wine but little political clout. There are larger inequities throughout the country. Many of these are historical and entrenched.

Data on the effects of reimbursement on physician decision making are not easy to come by. One study I found suggests that the time spent with patients may be less in the capitated, managed care environment than the traditional private practice. Another states that Medicare spending varies more than twofold among regions, and the variations persist even after differences in health are corrected for. The situation in McAllen, Texas is an eye-opening read.

The presence of guidelines is starting to homogenize practice patterns to an extent, but my perception is that there are still regional differences on both a macro and micro level. Practice guidelines which address testing exist ad nauseum, and while practices tend to move in the direction of compliance, a medical “climate,” like a corporate climate, is slow to change. Contributing factors are caution (“I just want to be extra sure that I’m right”), inertia or habit (“I’ve done it this way for 25 years”), ignorance (“There’s a guideline for this?”), and greed. Complicating change is the fact that, despite the presence of guidelines, there is no single “best practice” of medicine (good physicians may argue that I, for instance, do too little rather than they too much). Outcomes, of course, are the final arbiter, but these are notoriously difficult to track and compare, especially in patients that are increasingly older and more complex to manage. Everyone, after all, will die at some point. And if they don’t, they will get sicker, even with the best of care.

Last, patient expectations are high and get higher as we become more successful at managing (alas, rarely curing) chronic disease. Not getting that expensive test is often regarded as poor medical practice, and can lead to dissatisfaction on the part of the patient or family, and lawsuits. We’ve helped to make the bed we’re sleeping in.

It’s evident from the above that the factors fueling doctor over-utilization are complex and don’t have a single, simple answer. But any “solution” that doesn’t address this is fundamentally flawed, and destined for failure.

And we can’t afford failure.


NEXT:  The Insurance Companies


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  1. Frank Holtemann Says:

    Very interesting series of articles. I read them all. Thanks for directing me to your site. While I have none of your experience with the medical profession, I found most of your points made “common sence”. How do you get the politicians to listen?

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