Progressive health reformers need doctors to change the health system

Progressive health reformers need doctors to change the health systemDoctors order too many tests.

That’s not a surprise for regular readers of this site, but even the physicians themselves think so.

A recent survey reported that, “42% of the 627 respondents believed the patients in their own practice were getting too much care. Just 6% of doctors believed their patients were getting too little care … And 28% of the doctors thought they themselves were practicing more aggressively than they would prefer to.”

As to why, the study pointed to an oft-controversial reason: defensive medicine.

The survey, the results of which were published in the latest Archives of Internal Medicine, found 76% of doctors blamed malpractice worries for their over-aggressive care. The impact of defensive medicine has been debated, but “it is certainly the most widely endorsed external factor cited by physicians,” says Brenda Sirovich, an author of the study and a staff physician and research associate in the Outcomes Group at the VA Medical Center in White River Junction, VT.

Sirovich, also an associate professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice, notes that 83% of physicians thought they could easily be sued for failure to order a test that was indicated, but only 21% thought they could be sued for ordering a test that wasn’t indicated.

The incentives point toward “when in doubt, do more,” she says.

That’s true. There is little penalty for over-testing, but the potential for doing too little is harsh. Stories are powerful, like this one from Daniel Merenstein, who failed to order a PSA test and paid the price.

Physician health policy expert Aaron Carroll gives his progressive take on the study, saying that malpractice fears are overblown:

Well, three-quarters of primary care physicians say that concerns about being sued make them practice more aggressively than they’d like. But research shows that physicians in low malpractice risk areas don’t practice much differently than docs in high malpractice risk areas. They also don’t practice much differently after tort reform passes. You’ve heard me talk about how Texas’ malpractice reform didn’t bring spending down much at all.

And he calls physicians who don’t think money influences their decisions “delusional.”

Perception is strong. Despite progressive dogma that downplays the importance of malpractice, that view is clearly not shared by the majority of doctors. Policy experts can cite as many statistics as they want, but in order to convince doctors and sway practice patterns, they have to empathize with physicians’ plight. Taking an antagonistic stance, and calling physicians “delusional” is only going to further the tension between doctors and health policy experts.

Progressive health reformers need doctors to change the health system, despite their inherent distaste for physicians. It would be to their benefit to offer malpractice olive branches and get something back in return, rather than dismissing a problem that the majority of physicians care deeply about.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of, also on FacebookTwitterGoogle+, and LinkedIn.

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  • Anonymous

    Carroll’s comment is just plain weird.  To be fair, it might be taken out of context, but he seems to say that physicians in low risk areas and high risk areas practice similarly. Ergo, malpractice risk does not influence doctor behavior.  Huh?  That is a non sequitor.
    It could that doctors in both types of areas order more than they would if malpractice risk were not an issue, but doctors in some areas simply worry more than others, rationally or irrationally.
    Also, it could be than true risk is not the problem, rather doctors’ perception of risk. 
    Sorry, progressives, you might not like us docs, but you’re kinda stuck with us, flaws and all.  I invite you all to cowboy up and go to 4 years of medical school and and a minimum of 3 years of residency and then just show us all how it should be done.  Up for that?

    • John Fullwood

      Speaking as a progressive, I think the majority of us have far more troubles with the insurance industry than with doctors. I think a lot of the reason why so many progressives are against malpractice insurance is that it tends to be used as a reform in and of itself. As a package I imagine many would accept malpractice reform as a part of a more comprehensive thing while rejecting it by itself. Then again I also think that the tuition of doctors should probably be subject to more assistance especially those who go into primary care.

      • Anonymous

        I agree with your reasonable comments.

      • kevinmd

        There are many doctors who would trade comprehensive malpractice reform for progressive ideals, such as physician reimbursement reform. 

        Why progressives don’t use malpractice as a bargaining chip is, frankly, a missed opportunity.


        • John Fullwood

          I’d say a mix of trial lawyers generally being a more consistent demographic for the democratic party, optics, and fractousness and in general being great at shooting ourselves in the foot.

  • Margalit Gur-Arie

    I don’t think it is necessary to lay the foundation for yet another myth in this thorny health care debate.
    There are plenty of progressive doctors, and there are plenty of progressively inclined citizens who would support a fair reform of the malpractice situation. The key word being fair.
    I can see where some health policy experts advocating the administration’s point of view may come across as disliking doctors or at least having no concern for the physician point of view, but these folks are by and large representing themselves exclusively and should not be confused with the large numbers of Americans who are less vocal, less visible and who are as disenfranchised in this debate as the vast majority of practicing physicians.

  • Craig Koniver

    I really like your perspective here. As physicians we are faced with the tremendous threat of being sued. This feeling cannot be captured with statistics revealing malpractice lawsuits, etc. The idea of being sued is the scary part. If that occurs, we feel that our livelihood is literally at stake. Our medical license is sacred to us and for any outsider to think that it is not a big deal, does not understand this concept. 

    So for me, I don’t think we can wait for the outside policy world to change–I think it is something we have to do on our own. The only protection, to me, is working on developing deep connections with my own patients. By doing so, I can put my mind at ease because I trust them and they trust me. Because I strive to do this with all of my patients, I am able to sleep better at night. I am human and not perfect and will miss something here or there (we all will as doctors) but by having a trusting relationship with my patients, I can practice medicine without the threat of being sued all the time.

    I think the only way we as physicians are going to make significant strides in the malpractice arena is to focus on our own individual practices and patients because having to rely on outside policy makers who cannot comprehend what our thoughts are fears are, will not get us far at all.

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