Less autonomy than you might think

Physicians base their medical decisions on the clinical training they have received in school, practice of that knowledge during residency, and the vast experiences they have confronted during their career...right?? Well, not exactly.

A 2010 survey conducted by Health Leaders Media examined the external forces that affect physicians' decision-making. The study came in response to discussions about health reform in which proponents cite unnecessary tests prescribed by doctors (due to external pressures) as a major cause for rising health care costs. From the article:

While most doctors make clinically-sound decisions for nearly all patients, there are external pressures that can influence and increase the tests and procedures doctors order at the margins. An occasional unnecessary test times thousands of physicians and millions of patient encounters can quickly equal billions in unnecessary healthcare spending.

The survey measured four major factors: patients, fear of malpractice lawsuits, reimbursements/revenue considerations, and pressure from administrators and other third parties. There were some interesting results.

27.5% of physicians surveyed said that patients were a major influence, while 54.6% said they had a minor influence on medical decisions. This category measured how patients' requests determined medications, treatments plans, or tests. I have a feeling this number will continue to increase as pharmaceutical companies invest more money into marketing efforts aimed at getting patients to ask for certain drugs, tests, etc. Case in point: this article about patients requesting robot-assisted prostatectomies regardless of their doctors' recommendations largely due to the marketing efforts of specialists with the technology.

33.1% of respondents believe that fear of lawsuits has a major influence on decisions; 48.1% said malpractice has a minor impact. We have heard a lot of dialogue about malpractice or "tort" reform in the past several months. Perhaps these results will help push legislation through that limits the amount of a physician's influence (and cost) expended on fear of lawsuits.

30.2% indicated that reimbursement/revenue considerations had a major influence; 38.1% felt a minor influence on decision-making. I feel that this is a significant finding, especially as our health care system ponders whether or not to reform the way primary care physicians are paid. Clearly, reimbursement plays a role in the quality and nature of medical decisions.

11.2% of physicians said that pressures from administrators and other third parties had a major impact; 34.0% cited a minor impact. The article indicates that this is perhaps the most surprising finding and I agree. It is comforting to know that physicians can make medical decisions without overwhelming pressure from hospitals and health care groups to focus on the bottom line.

The point here is if you plan to go into medicine, be prepared to balance the many factors that affect a physician's decision. As if diagnosing a problem and prescribing a treatment plan weren't hard enough...