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Physicians as Patients

By July 9, 2019Commentary

If shared and informed decision-making between patient and treating physician will lead to better outcomes and more appropriate and cost-effective care, when the doctor is the patient we should see a clear movement toward those goals.  That is the question explored in a new National Bureau of Economic Research paper.   (NBER Paper)   In general, prior research has shown that most patients lack any substantial information on their health conditions or the treatment options related to those conditions.  This lack of data would obviously impair good decision-making and means that patients often default to whatever a clinician recommends.  The authors’ theory is that since physicians are uniquely well positioned to be informed decision-makers about the health care they receive, their behavior sets an upper bound on what we might expect from non-physicians.  It might also give us a sense of whether the issue in regard to health care decisions is lack of information or more related to either inability to use the information or non-rational factors that override factual information.  The research used ten years of data from the military health system and compared treatments received by physicians and non-physicians.  The comparison focused on supposedly objectively-determined high value or low value services.  The analysis included a number of adjustments to account for potential confounding differences between physicians and non-physicians.

The care examples used were Cesarean section delivery, which often is viewed as low-value; pre-operative testing before low-risk surgeries, specifically cataract removal and hernia repair, also viewed as low-value; indicia of good diabetes care; medication adherence for hypertension or high lipid levels and dependents’ vaccination rates, all designated as high-value care.  In the case of more discretionary Cesarean section delivery, physician mothers had a slightly lower rate, about three percentage points, compared to non-physician mothers; and dependent spouses of physicians showed no difference in this category of Cesarean.  Other than a slight decline in use of chest x-rays, there was no significant difference in the use of testing before low-risk surgeries between physicians and non-physicians.  Similarly, in regard to the high-value care, there was no significant evidence that physicians were more likely to comply with diabetes care guidelines or to be more medication-regimen adherent.  There were also very modest, at best, improvements in immunization rates.  The results clearly suggest that better information alone isn’t going to change health care decision-making in what is perceived to be a positive direction.  But this may be an artifact of our health system, including the military one.  When people don’t directly pay for the care they receive they have no incentive to be cautious, in fact, people may perceive receipt of any health service as reducing their risk of a bad health outcome, so since it doesn’t appear to cost them anything, why not do it.  Physicians are as likely to exhibit this behavior as any other patient.  So information likely needs to be coupled with some financial incentive to actually change behavior in regard to low-value care.  The explanation for why physicians don’t receive more high-value care is puzzling.  Perhaps they don’t think it is really all that valuable or makes that much difference it outcomes.  And general levels of receipt of this care may be high enough that it is hard to see differences between groups.

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  • I am disappointed but not surprised by these findings. While financial incentives may be a root cause of the behavior (or lack of behavior)….here’s another possibility.Education in healthcare decision-making can only be leveraged if the individual is empowered to use the information and to voice their opinion. Unfortunately, in the American culture (more so than in other Western cultures) we are wired/programmed to be rule-abiding and deferential to authority. (World Values Survey). As a result, even when physicians find themselves with a blue gown on….they fall into a culturally-consistent obedient behavior pattern and don’t use that knowledge/information to help direct their own care. So…what the treating physician says…goes.
    In published data as well as my own experience (when speaking with large audiences), it is amazing to me how many people (patients and physician/patients) fear MD retaliation if they dare ask questions. As a result, 86% of people who disagree with their physician’s recommendation are reluctant to voice that disagreement. ( As a result, my working thesis is that the investment in traditional health education is not effective until we invest in and drive a healthcare culture change that “levels the playing field” between patients and physicians and empowers patients to participate in their care (regardless of their level of professional expertise).

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