Abstract
Context
Unnecessary exposure to medical interventions can harm patients. Many hope that generalist physicians can limit such unnecessary exposure.
Objective
To assess older Americans’ perceptions of the need for tests and referrals that their personal physician deemed unnecessary.
Design
Telephone survey with mail follow-up in English and Spanish, conducted from May to September 2005 (overall response rate 62%).
Study Participants
Nationally representative sample of 2,847 community-dwelling Medicare beneficiaries. Main analyses focus on the 2,319 who had a personal doctor (“one you would see for a check-up or advice if you were sick”) whom they described as a generalist (“doctor who treats many different kinds of problems”).
Main Outcome Measure
Proportion of respondents wanting a test or referral that their generalist suggested was not necessary using 2 clinical vignettes (cough persisting 1 week after other flu symptoms; mild but definite chest pain lasting 1 week).
Results
Eighty-two percent of Medicare beneficiaries had a generalist physician; almost all (97%) saw their generalist at least once in the past year. Among those with a generalist, 79% believed that it is “better for a patient to have one general doctor who manages most of their medical problems” than to have each problem cared for by a specialist. Nevertheless, when faced with new symptoms, many would want tests and referrals that their doctor did not think necessary. For a cough persisting 1 week after flu symptoms, 34% would want to see a lung specialist even if their generalist told them they “probably did not need to see a specialist but could if they wanted to.” For 1 week of mild but definite chest pain when walking up stairs, 55% would want to see a heart specialist even if their generalist did not think it necessary. In these same scenarios, even higher proportions would want diagnostic testing; 57% would want a chest x-ray for the cough, and 74% would want “special tests” for the chest pain.
Conclusions
When faced with new symptoms, many older patients report that they would want a diagnostic test or specialty referral that their generalist thought was unnecessary. Generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will need to address their patients’ perceptions regarding the need for these services.
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References
Fisher, ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in Medicare spending: Part 2. Health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288–99.
Kravitz RL. Measuring patients’ expectations and requests. Ann Intern Med. 2001;134:881–8.
Peck BM, Ubel PA, Roter DL, Goold SD, Asch DA, Jeffreys AS, Grambow SC, Tulsky JA. Do unmet expectations for specific tests, referrals, and new medications reduce patients’ satisfaction? J Gen Intern Med. 2004;19:1080–7.
Van Bokhoven MA, Pleunis-van Empel MCH, Koch H, Grol RPTM, Dinant G, van der Weijden T. Why do patients want to have their blood tested? A qualitative study of patient expectations in general practice. BMC Fam Pract. 2006;7:75–82.
Keitz SA, Stechuchak KM, Grambow SC, Koropshak CM, Tulsky JA. Behind closed doors—management of patient expectations in primary care practices. Arch Intern Med. 2007;167:445–2.
Little P, Dorward M, Warner G, Stephens K, Senior J, Moore M. Importance of patient pressure and perceived pressure and perceived medical need for investigations, referrals, and prescribing in primary care: nested observational study. BMJ. 2004;328:444–7.
Kravitz RL, Callahan EJ, Paterniti D, Antonius D, Dunham M, Lewis CE. Prevalence and sources of patients’ unmet expectations for care. Ann Intern Med. 1996;125:730–7.
Kravitz RL, Callahan EJ. Patients’ perceptions of omitted examinations and tests. J Gen Intern Med. 2000;15:38–45.
Jackson JL, Kroenke K. The effect of unmet expectations among adults presenting with physical symptoms. Ann Intern Med. 2001;134:889–97.
Bell RA, Kravitz RL, Thom D, Krupat E, Azari R. Unsaid but not forgotten. Patients’ unvoiced desires in office visits. Arch Intern Med. 2001;161:1977–84.
Sirovich BE, Woloshin S, Schwartz LM. Screening for cervical cancer: will women accept less? Am J Med. 2005;118:151–8.
American Association for Public Opinion Research. Standard Definitions: Final Dispositions for Case Codes and Outcome Rates for Surveys,. Lenexa, KS: AAPOR; 2004.
Lewis CL, Wickstrom GC, Kolar MM, et al. Patient preferences for care by general internists and specialists in the ambulatory setting. J Gen Intern Med. 2000;15:75–83.
Institute of Medicine. Crossing the Quality Chasm. Washington DC: National Academy Press; 2001.
Schwartz LM, Woloshin S, Fowler F, Welch HG. Enthusiasm for cancer screening in the United States. JAMA. 2004;291:71–8.
Kravitz RL, Bell RA, Azari R, Kelly-Reif S, Krupat E, Thom DH. Direct observation of requests for clinical services in office practice. What do patients want and do they get it? Arch Int Med. 2003;163:1673–81.
Adamson J, Ben-Shlomo Y, Chaturvedi N, Donovan J. Ethnicity, socio-economic position and gender—do they affect reported heath-care seeking behavior? Soc Sci Med. 2003;57:895–904.
Wong MD, Asch SM, Andersen RM, Hays RD, Shapiuro MF. Racial and ethnic differences in patients’ preferences for initial care by specialists. Am J Med. 2004;116:613–20.
Kravitz RL, Callahan EJ, Azari R, Antonius D, Lewis CE. Assessing patients’ expectations in ambulatory medical practice. Does measurement approach make a difference? J Gen Intern Med. 1997;12:67–72.
Fiscella K, Franks P, Clancy CM. Skepticism toward medical care and health care utilization. Med Care. 1998;36:180–9.
Doescher MP, Saver BG, Franks P, Fiscella K. Racial and ethnic disparities in perceptions of physician style and trust. Arch Fam Med. 2000;9:1156–63.
Blanchard J, Lurie N. R-E-S-P-E-C-T: Patient reports of disrespect in the health care setting and its impact on care. J Fam Pract. 2004;53:721–30.
Sheppard VB, Zambrana RE, O’Malley AS. Providing health care to low-income women: a matter of trust. Fam Pract. 2004;21:484–91.
Halbert CH, Armstrong K, Gandy OH, Shaker L. Racial differences in trust in health care providers. Arch Intern Med. 2006;166:896–901.
King G, Murray CJL, Salomon JA, Tandon A. Enhancing the validity and cross-cultural comparability of survey research. Am Polit Sci Rev. 2004;97:567–83.
Acknowledgments
The authors would like to thank Jennifer Snide for her assistance with manuscript preparation. Dr. Herndon had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. This study was supported by a grant from the National Institute on Aging (PO1 AG19783) and from a Research Enhancement Award from the Department of Veterans Affairs. Dr. Herndon was supported by a faculty development grant from the Department of Medicine at Dartmouth-Hitchcock Medical Center. Drs. Woloshin and Schwartz were supported by Robert Wood Johnson Generalist Faculty Scholar Awards. The views expressed herein do not necessarily represent the views of the Department of Veterans Affairs or the United States Government.
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Herndon, M.B., Schwartz, L.M., Woloshin, S. et al. Older Patients Perceptions of “Unnecessary” Tests and Referrals. J GEN INTERN MED 23, 1547–1554 (2008). https://doi.org/10.1007/s11606-008-0626-9
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DOI: https://doi.org/10.1007/s11606-008-0626-9