Patient and Physician Perceptions of Dimensions of Necessity of Medical Utilization
Wagner, Peggy J., Warren, Peter R., Moseley, Ginger, The Qualitative Report
Given the increased strain on health care resources and the progressively pervasive public dependence on managed care over the last decade (Conrad, Bonney, Sachs, & Smith, 1996; Proenca, Rosko, & Zinn, 2000), the ability to distinguish appropriate uses of medical services from inappropriate uses or even misuse is becoming an important investigation area for health care providers. Historically, the health care provider's point of view represented the gold standard of correct or appropriate utilization of medical services. However, because medical visits involve both patient and provider, it becomes increasingly important to recognize that standards of medically appropriate visits may differ based on which side of the transaction one is located.
Physicians may view the repeat medical service consumer as manipulative, annoying, or "problem" misusers. Ironically, these worried well frequent consumers may really be motivated to make frequent visits as preventive measures because they assume a greater sense of personal responsibility for their health than do other patients (Wagner & Hendrich, 1993). Frequent users will seek care for minor symptoms in a much shorter time frame than would other patients (Wagner, Phillips, Radford, & Hornsby, 1995). People generally consider use of health care services as responsible health behavior, especially for preventive medicine, so such users may consider frequent medical services use to be appropriate, regardless of the cost-benefit ratio. Thus, physicians may view patients acting in a self-efficacious manner regarding their health with cynicism and annoyance.
Reports from older studies have shown that physicians relate "trivial or inappropriate" visits with lowered satisfaction in their practice (Mechanic, 1972), and that physicians in primary care disciplines (i.e., family practice, pediatrics, internal medicine) report higher incidents of "patient visits seen as unnecessary" (Barr, 1983). Additionally, chronic patients can be seen with a mechanical detachment, showing them less attention than others (Mietolla, Mantyselka, & Vaskilampi, 2005). These judgments are based largely on a pragmatic medical viewpoint, where diseases almost always have discernable biological causes and some possibility of treatment or palliative care. Quality health care providers look for movement towards improved clinical outcomes while minimizing costs, which is especially evident when a patient relies on for-profit managed care, where a factor of decision-making is shareholder profit increase (Born & Geckler, 1998). Thus, health care providers judge health care services to be appropriate based on the cost of treatment versus the potential outcomes, and view inordinate spending for repeated care of a single individual to be generally inappropriate. This perspective is particularly important in emergency cases, in which the services provided tend to be time critical, and staff effort is a finite commodity. One study of emergency room (ER) visits found that nurses and physicians felt that more than 20% of the visits would be more appropriate for a walk-in clinic or primary care physicians, and only 28.8% of patients attempted to contact their primary care physician before going to the ER (Harris, Bombin, Chi, deBortoli, & Long, 2004).
However, patients may see their problems as personally significant, thus defining a treatment or visit as appropriate based on their own subjective experiences rather than considering the overall cost-benefit ratio of repeated services. In fact, a review by Bernstein (2006) found that ER patients tended to be sicker than usual and required more health care in general. Therefore, the patient view of appropriateness may be defined in terms of factors such as symptom type and severity, duration and number of symptoms, and overall health.
Unfortunately, these symptom-level factors that may determine the appropriateness of medical utilization for a patient are major predictors of difficult doctor-patient relationships (Hahn, 2001). …