Why do Physicians Behave the Way They Do?

I believe that the vast majority of physicians do “the right thing” for their patients. I don’t think I’m being a Pollyanna. On the other hand, the “The Tragedy of the Commons”, which describes behavior in many cultures, doesn’t bypass the rod of Aescapelus. The story of “The Tragedy” reveals how individuals frequently tend to behave in a manner that satisfies short term personal goals rather than taking into account longer term outcomes of behavior that will benefit groups larger than a person’s close circle. This relates to the way that physicians behave relating to patient care.

There are several reasons that physicians “do things” for/to patients. The most common is that the individual physician honestly believes, based on his/her interpretation of information that is in their construct[1], that a diagnostic test or therapy will help the patient get better. When an appropriate test/treatment is provided to a patient, an improvement in health is most often the outcome. If the test/treatment is not appropriate, frequently either no benefit or an adverse outcome will result. (See “Who is responsible”). In addition to providing the right therapy, it should be in the right dose/form. It is not uncommon to see the phenomenon of the “treatment-paradox” where physicians will apply an effective therapy or test to those patients at low risk, but then avoid using the same procedure in sicker patients, who stand a greater absolute chance of benefiting. No one has adequately explained this behavior. In some instances it is related to contraindications to drug therapies in sicker patients. However, in many other instances there are no clear explanations (Peterson, P, et al: Circ Cardiovasc Qual Outcomes. 2010;3:309-315.).

A second explanation for physician behavior relates to experience embedded in the concept of “to a man with a hammer, everything looks like a nail that needs to be pounded”, When a physician is trained to do something, she/he becomes familiar with that and tends to use it because he/she believes it is beneficial. Who hasn’t heard a surgeon say, “A chance to cut is a chance to cure”? Physicians or surgeons who may be suspected of doing unnecessary procedures most often actually believe, because of this familiarity bias, that they are/were doing “the right thing”. I believe that this is partly why many physicians are still doing angioplasty/stent in patients with chronic stable angina before maximal medical therapy. They simply “believe” that angioplasty makes so much sense that it must “work”.

A third reason for physician choice in therapies may be that they are afraid to not do something because of fear of “liability exposure”. This has given rise to the malpractice debate. However, there are suggestions that even in regions where there is “tort reform”, physicians continue to apply procedures to avoid “malpractice risk”. Gawande, in his essay “The Cost Conundrum”, points this out. This behavior may relate to how badly physicians want to avoid legal confrontations even if the likelihood that they will personally loose much money is remote.

The elephant in the room, however, is when physicians do procedures for personal gain. He/she may duplicate a diagnostic test or therapeutic procedure because they know that they will be paid for doing it and that no one is going to check (How many of us read an explanation of benefits and understand it, much less inform our payer that a billed procedure wasn’t performed?). I have seen instances in which a physician group has a culture of doing repeat diagnostic tests exactly when payers say that they will pay for it. There are also instances in which patients are kept in hospital until the day insurance benefits run out, when miraculously the patient is “cured” or has received “maximal hospital benefit”. Many believe, even when it is difficult to prove, that this behavior is frequently applied to patients in psychiatric facilities.

Can unnecessary procedures, tests, therapies be identified and stopped? This will be difficult in a system where the culture is one of individual profit maximization and one where patients are not responsible for approving a bill before payment. Our current system of Relative Value Units or Diagnosis Related Groups as the basis for payment of physicians has led to the concept of “productivity”, which is often narrowly defined as how much one can bill. This is akin to the legal profession’s “billable hours”. (Does anyone remember the story of St. Peter talking to a lawyer who died at 45 years. When asked why now, St Peter said that he thought, based on hours billed, that the man had lived to be 100)? If this is the way that we will continue to pay (also called incentivize) physicians (and other caregivers) we will probably have physicians work only on treating patients, and doing as much as they can deliver. Taken to its “reductio ad absurdum”, payers would essentially be telling the physicians in our systems to do hands on care up to 10 -12 hours a day, keeping patients to themselves, not “sharing”. This would discourage working with “physician extenders”. It would also actively discourage our physicians from keeping time for other activities, which should improve medicine in general. Some of these outside activities would include: working on their own continuing education, or the continuing education of support staffs, participating in committee activities (which should help improve the way the system is run), participating in registries, working on improving quality locally or in national committees, or participating in community outreach (“free” clinics or community education). There are, I’m sure other things that we hope that physicians would participate in. We can, unfortunately, be fairly confident that there is no incentive to participate in any of these activities.