Medical decision making is influenced by patients, lawsuits, and money

Ideally, the medical decisions doctors make for their patients should be free of any outside influence.

But for regular readers of this blog, we know that’s not always the case.

A 2010 HealthLeaders Media Industry Survey identifies some factors that may influence a physician’s medical decision. Here are some of the results.

Pressure from patients was a significant influence, with only 17.9% of doctors saying it wasn’t a factor. Doctors often encounter patients who “demand a drug he saw advertised on television or ask for an extra test ‘just to be safe.’” When it comes to controlling costs, patient pressure is an underpublicized, yet significant, phenomenon.

Coming second is fear of lawsuits, which is unsurprising. One-third of doctors called it a “major influence,” more than any other factor. Health reformers who ignore defensive medicine is leaving a significant means of cost control on the table.

And, as I’ve mentioned previously, malpractice reform doesn’t have to include non-economic caps. The suggestion that doctors who follow evidence-based guidelines (which progressive reformers endorse, by the way) be protected from lawsuits is a good one.

The physician payment system, which encourages “more” medicine through a fee-for-service payment system contributes the third influence. Divorcing reimbursement from quantity of care can reduce this, but unfortunately, it’s nowhere to be found in the current reform plans.

And finally, pressure from administrators represents, surprisingly, the least influential factor. According to the study, “this reflects the greater emphasis placed on physician-hospital alignment in recent years, and the growing number of physicians who are employed by hospitals and health systems.”

There you have it. So when your doctor suggests a treatment option for you, it’s likely that one or more of these factors is contributing to the decision.

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  • Oculata Certitudine

    So … direct influence from pharmaceutical companies don’t make the top three for this list? I thought all those pads, pens, and free samples were the driving force.

  • http://www.drjshousecalls.blogspot.com Dr. Mary Johnson

    Kevin, one night in the middle-of-the-night, as a young physician in public service, I was forced to choose between a newborn baby’s life and my own career . . . placed in that position by two very over-rated, WAY overpaid mill-town hospital executives who were worried about their reputation and market share.

    I chose to help the baby (who was being horribly mis-managed by someone else) – by ALL accounts saving her life. It’s what anyone would have expected me to do. Indeed I might have been sued if I had rolled back over and gone to sleep.

    But the government I served (the one everyone wants to give more responsibility to) abandoned me to the wolves. It’s been an on-going twelve-year nightmare. I’ve lived with the consequences of that decision – the correct decision – EVERY DAY since.

    I should have been invitied to testify before Congress long ago (before the reformers even started reforming) – or tell my story on “60 Minutes” (so far, when it comes to the NHSC, Don Hewitt’s crew is only interested in puff pieces).

    Instead, I’ve been told to “get over it” and “move on” – when there is just NO WAY that can happen.

    Pressure (not just from patients), lawsuits and money. Yeah. That about covers it.

  • jrm

    So what do we do for all those conditions for which there is no evidence-based guidance regarding treatment? Or for which there is so much variation in the natural history of the disease or in the response to therapy that there is never going to be a single “best treatment?” I can assure you that my specialty (dermatology) is overflowing with such conditions.

  • http://www.futurewaredc.com Chuck Brooks

    The practice of medicine is exactly that, practice. No human decision happens in a vacuum, particularly when personal interests are so pronounced when health is involved. Whatever doctors may be, there certainly are not omniscient. Those who want to be pure and forever enlightened would do well to remove themselves to a monastary or some such.

  • http://www.ohiosurgery.blogspot.com buckeye surgeon

    Kevin-
    You put too much faith in the “evidence based” protective umbrella. I like the idea, but far too much of the decision making involved in medicine transcends simply referring to some cookbook algorithm of “best practices”. Treatments are individualized. Not every patient fits into pre-determined paradigms. Especially in surgery and critical care.

    Tort reform requires more than just making sure doctors are turned into mindless automatons ordering whatever UpToDate tells them to do. We need health courts, better intra-professional disciplining and monitoring, no-fault provisions, and some sort of screening mechanism to eliminate frivolous claims.

    • Jillian

      Applause.

  • jmw

    Is there any such thing as a “miss rate”? Even with the best available technology, and the best educated and trained physicians, many diagnoses are still consistently missed. Examples- Aortic Dissection is missed about 40% of the time on the initial patient encounter. Acute MI is missed 2-4% of the time, appendicitis- 2-3 %, etc.

    The medical establishment needs to do a better job convincing patients (and their lawyers) that the 100% diagnostic accuracy rate is absurd.

    • tgottsdo

      We all know about the positve/negative predictive value and the sensitivity/specificity of tests which together give the “odds” of having a false positive or false negative test result. (or true positive/true negative for that matter). I think this is a calculation that often goes on in our brains automatically and gets better with experience. I think that as I get more experienced I find that listening to intuition and that little voice in my head that says something isn’t right more often than not pays dividends. If we simply went by “evidence based” medicine we might as well be replaced my a computer.

  • jsmith

    jrm and buckeye make a key point. Much of what we do at a micro-level has not been adequately studied and never will be. Example: use of opioids together with SSRIs might increase the risk of serotonin syndrome. What is the absolute risk of this? What are the population-wide mortality and morbidity implications of this? Do the risks differ by pt sub-type? What do the evidence-based (not consensus or expert-opinion based, which are, in essence, the blind leading the blind) guidelines say? Answer: unknown.
    Guidelines only get you so far. But it gets worse. Guidelines, like any type of statistical decision making, are liable to the ecological fallacy, the mistaken idea that what is true for the average member of a group is also true for all members of that group. Funny how people just blow through this simple idea, which we all learned in stat 101.
    Statistical evidence is much better than no evidence, I grant you that. But it’s still just part of the puzzle. It’s our job to put the puzzle together.

  • dud

    I agree with Buckeye about health courts as a change that may make the legal process “fairer”, certianly in the eyes of physicians who seem to view the current system as corrupt.

    I am not so sure it will be a major cost saver though.
    Why does “defensive medicine” change based on the forum in which the dispute will be decided? There is still someone looking over your shoulder when there is an bad outcome. Whoever loses is going to not like the system, no one ever has.

    No fault seems to be the only way to get rid of this. However, is that the correct path?

  • PAUL MD

    The terms need to be defined regarding “medical liability insurance”.

    Currently it is named “malpractice insurance”. My understanding is that it is there and purchased in case of a malpractice claim.

    Dissatisfied patient and or bad outcome insurance is a different matter altogether.

    Is society supposed to be paying folks for less than optimum outcomes even when there is no malpractice? Are providers expected to pay for this?

    Should these entities be separated and dealt with in different manners?

    Lay people need to remember that we physicians are sometimes patients to. These are issues that concern us from both sides.

    I would agree that this does not address any cost containment. Unless there is true tort reform and safe harbors, overproviding will continue to be the norm. The President seems to have chosen to support his ilk in providing his trial lawyer friends fresh meat for their consumption. Because of this simple fact of selling out physicians, all of this supposed reform is a joke and will never have my support.

  • Primary Care Internist

    I agree with PAUL MD – the president should be wholeheartedly rejected by ANY practicing MD, due to his and Pelosi’s gift to shady trial lawyers. Same for the AMA, who just bend over and take it from them all, smiling with their silly white coats in press conferences (much like Mehmet Oz on his show, in scrubs as if he just performed a CABG in the operating room).

  • Matt

    “Is society supposed to be paying folks for less than optimum outcomes even when there is no malpractice?”

    No, it’s not. That’s why we have trials to determine the difference.

    “. The President seems to have chosen to support his ilk in providing his trial lawyer friends fresh meat for their consumption.”

    Or maybe he believes in individual rights and thinks a jury is far better situated to decide the value of a case after having heard the evidence in the case than some politicians picking a random number chosen by insurance lobbyists. Or maybe he believes in the Constitution – specifically the 7th Amendment.

    Or maybe, just maybe, he’s heard “give us tort reform and costs will go down”, and he’s looked around at every state it’s been tried over the past 30 years, and found that IT ISN’T TRUE. Capping damages doesn’t do anything but reduce insurer risk from claims of those injured the worst. Doesn’t reduce premiums, doesn’t reduce cost of care, and doesn’t affect access. So why would he give insurers that gift for nothing in return? And at the expense of those injured the worst?

    Or maybe he just likes the campaign donations, just like the Repub party likes the donations from the “reformers”.

  • tgottsdo

    The stated goal of Health Care reform is to lower costs and provide care for all Americans. I don’t feel that tort reform will significantly lower costs. It would be better for physicians and better for the country as a hole to be less litigious. I would be in favor of screening boards to work out the medical issues of a dispute prior to trial and more liberal use of binding arbitration. But this is a state issue and needs to be addressed at that level.
    The real cost savings will come when people realize that insurance is what drives healthcare costs ever upward. Or I should say having third party payors… whether the third party is the government or an insurance company. When the actual consumer of a product or service has no clue as to the cost of said service there is no incentive to lower costs or shop for lower prices. As a primary care provider I’m told that I get an average of $54 dollars per visit… but to get that i have to bill $170 to the insurance co.. Then when a patient comes in as a cash pay and asks what we charge we have to say $170. That would lead someone to say that the costs of healthcare are out of control… when in reality I would be happy to see that patient for $60 cash. Does anyone believe that there would be medicine that costs $400/month if people actually paid $400/month? Like VCRs and DVD players the cost would rapidly decline to what people were willing to pay… especially if you were the 3rd or 4th entry into a market. I think one of the best innovations in Medicine in the last few years is the WalMart $4 prescription plan… We’ve all seen what that has done to the market. The second unintentioned consequence of insurance is that patients are under the impression that everything is free or little cost if you have insurance. I strongly feel that if we want to truely lower health care costs then we need to have less insurance and not more… I think the ideal system would be the Health Savings account with a high deductible insurance plan for hospitalization and excessive costs.

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