By Dr. Kate Scannell, Syndicated columnist
First Published in Print: 10/01/2011
Vince Lombardi once famously declared that, in football, "The best defense is a good offense."
I thought about the coach's words while reading a new study about doctors ordering unnecessary medical tests and procedures -- whether practicing medicine on the defense or offense. The study was eye-opening in that it surveyed views about unnecessary medical care from the unique perspectives of 627 U.S. physicians on the front-line of medical practice -- internists and family practitioners who often call the plays that determine whether tests or subspecialty referrals are ordered.
In essence, this report in last week's Archives of Internal Medicine reveals that many doctors, by their own admission, believe that too many patients get too much care. And, after analyzing the explanations proposed by the doctors, the authors offer this striking conclusion: "Physicians believe they are paid to do more, and exposed to legal punishment if they do less."
This finding may not surprise many readers. After all, it's been long suspected that depressingly vast amounts of health care dollars are wasted on unnecessary medical care and administrative overhead -- between one-third to one-half of our nearly $2.5 trillion in annual health care spending, according to various analysts.
And much has already been written about doctors practicing "defensive medicine" -- ordering medically unnecessary tests or procedures, hoping to reduce their perceived risk of being sued.
In fact, a separate report issued last week by Jackson Healthcare estimated that defensive medicine alone costs our health care system $650 billion-850 billion each year.
Still, these renewed claims of wasteful spending gain tremendous poignancy against the current backdrop of our economic crisis, our high unemployment and poverty rates, and our growing number of uninsured Americans.
Clearly, our health care dollars could be more judiciously spent and more fairly distributed to even the playing field for destitute Americans seeking health care.
The new Archives study merits further attention precisely because its findings are based on a survey of randomly selected primary-care physicians -- doctors in positions to offer unique Monday-morning quarterbacking about our national medical expenditures.
In this regard, its most remarkable finding was that fully 42 percent of the doctors believed that their own patients were receiving too much medical care. Furthermore, nearly three in 10 admitted to ordering more tests and specialist referrals than they would "ideally like to."
When asked to explain these behavioral phenomena, the doctors -- not surprisingly -- most often cited malpractice fears as motivation (76 percent). But two additional factors remained highly influential. More than half of the doctors claimed that delivering "too much" care was motivated by demands to satisfy "clinical performance" metrics; and 40 percent attributed inadequate time to spend with patients as playing a decisive role.
It is both amazing and disturbing to learn that so many dollars and health care resources are being used to treat doctors' anxieties and fears. Medicine practiced on the defensive -- against lawsuits, bad performance reviews, and insufficient time with patients -- can't be healthy for anyone, suffering doctors included.
Lastly, the new study also confirmed a common perception among doctors that delivering "too much" care is often motivated by doctors seeking financial profit -- a practice we might refer to as "offensive medicine". For example, whether correct or not, more than 60 percent of primary-care doctors believed that medical testing would be reduced if it did not generate revenues for medical subspecialists.
Obviously, whether practicing medicine on the offense or defense, doctors play a critical role in determining how our health care dollars are spent.It will be impossible to tackle cost containment and health care reform without addressing malpractice reform, pay-for-performance metrics, systems issues that deprive doctors and patients of time together and financial incentives that simply reward doctors for how many tests or procedures they order.
And yet ... I worry that these initiatives merely address surface fixes for our broken system. More deeply problematic is that many of us -- doctors and patients both -- have lost sight of medicine's primary endgame: to promote human health.
We've allowed medical practice to become an expensive, bloated sideshow -- scripted to keep the lawyers out of the audience, to win popularity contests for doctors, to generate easy profits for physicians at patients' expense.
We doctors and patients have moved the goal posts much too far to accommodate new objectives serving our new identities as "service providers" and health care "consumers."
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Kate Scannell is a Bay Area physician and the author of "Flood Stage."
Copyright 2011, Kate Scannell