Patient Requests for Inappropriate Services

One alleged cause of high health spending in the US is the delivery of inappropriate or unnecessary care.  One potential reason for this is patients’ requesting that a physician deliver or order certain care.  Research published in the American Journal of Managed Care uses data from a 2009 survey of 840 primary care physicians to ascertain how frequently patient care requests led to services or orders that the physician believed were likely unnecessary.   (AJMC Article)   Two common situations were examined.  One was ordering brand name drugs and the other was giving referrals to specialists.  52% said they sometimes or often made referrals they believed unnecessary and 39% said they ordered a brand-name drug for a patient when a generic was available, based on the patient’s request.  Only 11% of doctors said they never made a requested referral they thought was unnecessary.  43% of pediatricians made unnecessary referrals, as did 56% of family practice physicians and 53% of internal medicine doctors.  Only 18% of pediatricians prescribed a brand-name medication when generics were available, compared to 39% of family practice and 50% of internal medicine physicians.  Factors that were associated with more likelihood of responding to patient pressure for services included having fewer uninsured and Medicaid patients, being older, having met with drug or device company sales people, and practicing in a smaller group.

Surveys show increasing frustration and job dissatisfaction among physicians.  Among other things, this unhappiness means that the people who may make the best physicians are unlikely to go into the profession, which isn’t good for health care quality.  We are making physicians’ lives miserable with conflicting directives and excessive regulations, such as “quality improvement” initiatives and health information technology mandates.  We ask them now to not just try to maximize their patients’ health, but to consider cost when caring for their patients, and at the same time to engage in “shared decision-making” that recognizes patient preferences.  And their reimbursement is often tied in part to patient satisfaction scores.  Spending control is important, particularly since patients now often pick up much of the cost, but so is recognizing professional judgment and honoring patient preferences.  No wonder doctors have less satisfaction with their jobs.