Too Much Care?

Do Your Patients Receive “Too Much” Care?

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In the ongoing debate that is fueling healthcare reform, there are concerns that controlling medical costs must include the rationing of healthcare services. However, other health economists and epidemiologists have suggested that much of U.S. healthcare is unnecessary and overly aggressive.[1]

Compelling results from a nationwide survey of primary care physicians (PCPs) were recently published in the Archives of Internal Medicine,[2] citing that many respondents believed their patients received too much care. The survey was sent in 2009 to 627 primary care and general internal medicine physicians randomly selected from across the United States. Respondents were overwhelmingly male (72%) and board-certified (88%), with an average of 24 years in practice.

Each responding PCP was asked to answer two questions about patients in his/her own practice and a third question about other healthcare providers in the community using a 5-point Likert scale.

  • Do patients in your practice receive too much or too little medical care?
  • Do you currently practice more conservatively or aggressively (ie, ordering fewer or more tests and services) than you would like?
  • How would you describe the practice style of other PCPs, nurse practitioners and physician assistants, or specialists in the community?

In addition, PCPs were asked to rank a series of factors that influence them to order diagnostic tests and referrals as well as whether scheduled primary care visits to their practice could be handled by phone, email, or nonphysician staff.

What Your Colleagues Said

Nearly half (42%) of all survey respondents believe that patients in their own practice receive too much medical care, while only 6% believe that their patients receive too little care. Just over half (52%) believe the amount of care received is just right. Additionally, 28% said they personally were ordering more tests and referrals than they would like, and 29% percent felt that other PCPs in the community were doing the same.

More than 75% of the respondents cited malpractice concerns as the most significant factor influencing them to practice more aggressively—83% believed they might be sued for not ordering an indicated test, while 21% believed they would be sued for ordering a test that was not indicated. Slightly more than half of the respondents reported that adherence to clinical practice measures—a metric used to evaluate physicians’ performance—was a factor in encouraging aggressive medical practice, while 40% cited inadequate time to spend with patients as a factor in ordering medical tests and procedures. Almost half (45%) of the doctors surveyed estimated that at least 10% of the patients they see on a typical day could be managed by a visit with a nurse or an email or phone consultation, although reimbursement for some of these strategies is negligible to nonexistent.

Only 3% of the respondents indicated that financial incentives influenced their practice style. However, when asked about their colleagues—including nurse practitioners, allergists, gastroenterologists, cardiologists, and endocrinologists—almost two-thirds of the respondents indicated that financial incentives were most likely driving overtreatment.

One of the more interesting findings from the survey was that more than 75% of the PCPs were interested in learning more about how they measured up to other physicians in the community.

What Can Be Done?

There are numerous roadblocks to defusing aggressive medicine. Changing the medical malpractice system is no small task. It could be years until doctors are reimbursed for spending more time with patients or communicating with patients via email or phone. And the effect of clinical performance measures on aggressive practice has yet to be determined.

While you wait for healthcare reform to wend its way down into clinical practice, Dr. Calvin Chou of the University of California–San Francisco suggests two specific approaches you can use now to decrease aggressive practice: patient-centered communication and mindfulness.[3]

Patient-centered communication is the cornerstone of communicating effectively with your patients.[4] This type of communication affords patients the opportunity to share their perspective on the impact of their illness and for you to educate patients about their care. Studies show that this type of dialogue is especially important and can positively impact patient outcomes such as decreases in anxiety and blood sugar and blood pressure, as well as metrics related to pain management.[5]

You can benefit from patient-centered communication as well. Aside from building better relationship with patients, clinicians who listen to their patients are less likely to be sued.[6] In a study of family practitioners and general internists, doctors who educated patients about what to expect during an office visit, laughed and used humor throughout the examimation, solicited patient’ opinions, and encouraged them to talk were significantly less likely to be sued.

Mindfulness refers to the mental quality of being fully present and attentive in the moment and to disengage from preconceived beliefs, thoughts, and emotions.[7] This mindful state is characterized by less judgment, prejudice, and worry and more openness, acceptance, and empathy. Some data suggest that PCPs who are trained in mindfulness, communication, and self-awareness showed decreased burnout, improved well-being scores, and increased capacity in relating with patients.[8]

It is obviously going to take more than just good communication skills and an open mind to become a less aggressive PCP. The reimbursement and malpractice issues loom large and overwhelming. The good news is that many PCPs recognize the problem and have expressed interest in learning where they stand in comparison with their peers.  That’s an excellent first step.

Jill Shuman, MS, ELS
Published October 4, 2011


  1. Gawande AA, Fisher ES, Gruber J, Rosenthal MB. The cost of health care—highlights from a discussion about economics and reform. N Engl J Med. 2009;361(15):1421-1423.
  2. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585.
  3. Chou C. Nice work if you can get it: Comment on “Too little? Too much? Primary care physicians’ views on US health care.” Arch Intern Med. 2011;171(17):1585-1586.
  4. Epstein RM, Mauksch L, Carroll J, Jaén CR. Have you really addressed your patient’s concerns? Fam Pract Manag. 2008;15(3):35-40.
  5. Stewart MA. Effective physician-patient communication and health outcomes: a review. CMAJ. 1995;152(9):1423-1433.
  6. Levinson W, Roter DL, Mullooly JP, et al. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. JAMA. 1997;277(7):553-559.
  7. Ludwig DS, Kabat-Zinn J. Mindfulness in medicine. JAMA.2008;300(11):1350-1352.
  8. Krasner MS, Epstein RM, Beckman H, et al. Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians. JAMA. 2009;302(12):1284-1293.