Our findings show that elderly Americans value generalist physicians: more than 80% have a generalist physician and about the same proportion say it is better to have 1 generalist manage their problems than multiple specialists. This finding is consistent with previous work.13
At the same time, our findings suggest that older patients may hold fast to their ideas that more tests and referrals are needed even when their generalist provides advice to the contrary. In response to our vignettes, 30% to 75% of patients said they would want a diagnostic test or specialty referral that their generalist thought was unnecessary.
We think our findings reflect 2 things. First, there is a growing consensus that high-quality primary care involves shared decision making between physicians and their patients.14
A central tenet of shared decision making is that patients bring their own values and expectations to any medical encounter. Older Americans clearly endorse this view. Large majorities of Medicare beneficiaries said they see their role in managing their own illnesses as being just as important as that of their doctor, and 9 of 10 said they feel very or somewhat confident in doing so.
Second, patients seem to be predisposed to want “more” care. Studies have shown that many patients arrive at appointments with an expectation that they will receive a diagnostic test, a specialty referral, and or a prescription.Table 3,4,9
Research on patient attitudes toward cancer screening tests have shown that most Americans think standard screening tests are almost always a good idea and cannot do much harm.11,15
Further, Americans seem resistant to the idea of doing less. In a nationally representative survey of Americans, most said that “if a physician recommended you stop having or have less frequent [pap tests, mammograms, psa tests, sigmoidoscopy/colonoscopy]” they would still keep on having the tests as frequently as before.15
Another key finding in our study was that desire for tests and referrals varied significantly by gender and race. Women reported wanting fewer tests and referrals than men. Data on gender differences in patient expectations is limited. In a study of 559 audio-taped office visits of patients with a mean age of 55, women made more requests than men.16
However, this was a small study conducted among younger patients, using a different methodology. Our study also showed that compared to Whites, Blacks, and non English-speaking Hispanics reported wanting more tests and referrals. These findings are consistent with a previous study assessing patient perceptions of the urgency of seeking care among an urban population.17
However, our findings contrast with a waiting room study of 646 patients in 3 urban academic Internal Medicine practices, which found that compared to Whites, Blacks and Asians were less likely to prefer initial care by specialists.18
Differences in both measurement approach and sampling strategy may explain some of these differences.2,19
The idea that offering less care can be interpreted by patients as a withholding of valuable care (as opposed to avoiding unnecessary or even dangerous care) may in part explain why our findings varied by race and ethnicity. Previous work has shown that patients from ethnic minorities may be less likely to trust their physician.20–24
These patients may in turn be less likely to find reassurance in their doctors’ advice that further tests and referrals are not needed.
Our study should be interpreted in light of several limitations. First, as with any survey, there is the possibility of non-response bias. Our findings could be biased if the most passive patients—people who would accept physician recommendations without question—were overrepresented among non-respondents. Our response rate of 62% (65% for the national random sample and 45% for the African-American oversample) mitigates this concern, and it should be noted that this is quite a good response rate for a national survey. In addition, the demographic characteristics of our sample are very close to those of the sampling frame—20% of the 2004 Medicare denominator file (see Table ), suggesting that non-response was a random phenomenon (at least with regards to these characteristics).
Second, some readers may be concerned about the use of clinical vignettes to measure patients’ desire for tests and referrals. We could not logistically study actual responses in a real-time situation—and even if we could, contextual differences would make it extremely difficult to interpret the results. In fact, this is the distinct advantage of using vignettes: all respondents are exposed to the same situation, controlling for differences in context.25
Further, it is reassuring that responses to the vignettes demonstrated construct validity—more patients reported a desire for tests and referrals for the potentially serious symptom (chest pain) than for the relatively minor symptom (cough after the flu). The combination of large sample size and use of the clinical vignette allowed us to construct a robust statistical model to make valid between-group comparisons, e.g., non-Hispanic White vs Black vs Hispanic.
Good physicians help patients get the care they need, neither more nor less. Our findings suggest that generalists striving to provide patient-centered care while at the same time limiting exposure to unnecessary medical interventions will face a difficult balancing act. It is not hard to understand where patients’ enthusiasm for medical interventions comes from. A host of sources, including disease promotion campaigns, direct to consumer drug ads (and, increasingly, ads from academic medical centers), and a media eager to tout the newest health risk or miracle cure bombards them with the message that more care is always better. All these forces push in the direction of doing more. Generalists have the opportunity to act as a countervailing force by working in a shared decision-making mode to address their patients’ expectations explicitly and by highlighting for their patients that good medical decision making almost always involves considering both the benefits and harms of interventions. If generalists want patients to do less, they will need to do more.