tors: predictors of voluntary disenrollment from a primary physician’s practice.J Fam Pract. 2001;50(2):130-136.

6. Rao JK, Weinberger M, Kroenke K. Visit-specific expectations and patient-centered outcomes: a literature review. Arch Fam Med. 2000;9(10):1148-1155.

7. Sequist TD, Schneider EC, Anastario M, et al. Quality monitoring of physicians:linking patients’ experiences of care to clinical quality and outcomes. J Gen In-tern Med. 2008;23(11):1784-1790.

8. Chang JT, Hays RD, Shekelle PG, et al. Patients’ global ratings of their healthcare are not associated with the technical quality of their care. Ann Intern Med.2006;144(9):665-672.

9. Kravitz RL, Epstein RM, Feldman MD, et al. Influence of patients’ requests fordirect-to-consumer advertised antidepressants: a randomized controlled trial.JAMA. 2005;293(16):1995-2002.

10. Macfarlane J, Holmes W, Macfarlane R, Britten N. Influence of patients’ expec-tations on antibiotic management of acute lower respiratory tract illness in gen-eral practice: questionnaire study. BMJ. 1997;315(7117):1211-1214.

11. Pham HH, Landon BE, Reschovsky JD, Wu B, Schrag D. Rapidity and modalityof imaging for acute low back pain in elderly patients. Arch Intern Med. 2009;169(10):972-981.

12. Fisher ES, Welch HG. Avoiding the unintended consequences of growth in medi-cal care: how might more be worse? JAMA. 1999;281(5):446-453.

13. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The im-plications of regional variations in Medicare spending, part 2: health outcomesand satisfaction with care. Ann Intern Med. 2003;138(4):288-298.

14. Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The im-plications of regional variations in Medicare spending, part 1: the content, qual-ity, and accessibility of care. Ann Intern Med. 2003;138(4):273-287.

15. Landrum MB, Meara ER, Chandra A, Guadagnoli E, Keating NL. Is spending morealways wasteful? the appropriateness of care and outcomes among colorectalcancer patients. Health Aff (Millwood). 2008;27(1):159-168.

16. Sirovich B, Gallagher PM, Wennberg DE, Fisher ES. Discretionary decision mak-ing by primary care physicians and the cost of U.S. health care. Health Aff(Millwood). 2008;27(3):813-823.

17. Deyo RA, Mirza SK, Martin BI, Kreuter W, Goodman DC, Jarvik JG. Trends, ma-jor medical complications, and charges associated with surgery for lumbar spi-nal stenosis in older adults. JAMA. 2010;303(13):1259-1265.

18. Wiener RS, Schwartz LM, Woloshin S. Time trends in pulmonary embolism inthe United States: evidence of overdiagnosis. Arch Intern Med. 2011;171(9):831-837.

19. Gerstein HC, Miller ME, Genuth S, et al; ACCORD Study Group. Long-term ef-fects of intensive glucose lowering on cardiovascular outcomes. N Engl J Med.2011;364(9):818-828.

20. Jarvik JG, Hollingworth W, Martin B, et al. Rapid magnetic resonance imagingvs radiographs for patients with low back pain: a randomized controlled trial. JAMA.2003;289(21):2810-2818.

21. Cohen JW, Cohen SB, Banthin JS. The Medical Expenditure Panel Survey: a na-tional information resource to support healthcare cost research and inform policyand practice. Med Care. 2009;47(7)(suppl 1):S44-S50.

22. Centers for Disease Control and Prevention. NHIS linked mortality public-use files.http://www.cdc.gov/nchs/data_access/data_linkage/mortality/nhis_linkage_public_use.htm. Accessed May 16, 2011.

23. Agency for Healthcare Research and Quality. CAHPS: surveys and tools to ad-vance patient-centered care. 2011. https://www.cahps.ahrq.gov/default.asp. Ac-cessed March 10, 2011.

24. Hargraves JL, Hays RD, Cleary PD. Psychometric properties of the ConsumerAssessment of Health Plans Study (CAHPS) 2.0 adult core survey. Health ServRes. 2003;38(6, pt 1):1509-1527.

25. Ware J Jr, Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: con-struction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233.

26. Ware JE Jr, Kosinski M, Bayliss MS, McHorney CA, Rogers WH, Raczek A.Comparison of methods for the scoring and statistical analysis of SF-36 healthprofile and summary measures: summary of results from the Medical Out-comes Study. Med Care. 1995;33(4)(suppl):AS264-AS279.

27. Kadam UT, Schellevis FG, Lewis M, et al. Does age modify the relationship be-tween morbidity severity and physical health in English and Dutch family prac-tice populations? Qual Life Res. 2009;18(2):209-220.

28. DeSalvo KB, Fan VS, McDonell MB, Fihn SD. Predicting mortality and healthcareutilization with a single question. Health Serv Res. 2005;40(4):1234-1246.

29. Fleishman JA, Cohen JW, Manning WG, Kosinski M. Using the SF-12 health sta-tus measure to improve predictions of medical expenditures. Med Care. 2006;44(5)(suppl):I54-I63.

30. Kravitz RL, Cope DW, Bhrany V, Leake B. Internal medicine patients’ expecta-tions for care during office visits. J Gen Intern Med. 1994;9(2):75-81.

31. Kravitz RL, Bell RA, Azari R, Krupat E, Kelly-Reif S, Thom D. Request fulfillmentin office practice: antecedents and relationship to outcomes. Med Care. 2002;40(1):38-51.

32. Marple RL, Kroenke K, Lucey CR, Wilder J, Lucas CA. Concerns and expectationsin patients presenting with physical complaints: frequency, physician perceptionsand actions, and 2-week outcome. Arch Intern Med. 1997;157(13):1482-1488.

33. Bertakis KD, Azari R. Patient-centered care is associated with decreased healthcare utilization. J Am Board Fam Med. 2011;24(3):229-239.

34. Epstein RM, Franks P, Shields CG, et al. Patient-centered communication anddiagnostic testing. Ann Fam Med. 2005;3(5):415-421.

35. Stewart M, Brown JB, Donner A, et al. The impact of patient-centered care onoutcomes. J Fam Pract. 2000;49(9):796-804.

36. Peck BM, Ubel PA, Roter DL, et al. Do unmet expectations for specific tests, re-ferrals, and new medications reduce patients’ satisfaction? J Gen Intern Med.2004;19(11):1080-1087.

37. Deyo RA, Diehl AK, Rosenthal M. Reducing roentgenography use: can patientexpectations be altered? Arch Intern Med. 1987;147(1):141-145.

38. Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primarycare. J Gen Intern Med. 2005;20(10):953-957.

39. Flocke SA, Miller WL, Crabtree BF. Relationships between physician practice style,patient satisfaction, and attributes of primary care. J Fam Pract. 2002;51(10):835-840.

40. Audet AM, Davis K, Schoenbaum SC. Adoption of patient-centered care prac-tices by physicians: results from a national survey. Arch Intern Med. 2006;166(7):754-759.

ONLINE FIRST

Scan for AuthorAudio Interview

INVITED COMMENTARY

How to Feed and GrowYour Health Care System

N ot long before the editorial deadline for thisInvited Commentary, I headed off onvacation to warmer climes (this is not diffi-

cult when leaving from northern New England). Butwould a week in tropical paradise be worth the frus-tration and indignity of commercial air travel? It turnsout I was lucky. The lead flight attendant ran a

tight ship, assuring us an orderly, safe, and comfort-able trip. Maybe I should plan more discretionarytravel.

According to the findings of a study published in thisissue of the Archives, had my recent shoulder surgery gonemore smoothly, I might instead be planning more dis-cretionary health care.

ARCH INTERN MED/ VOL 172 (NO. 5), MAR 12, 2012 WWW.ARCHINTERNMED.COM411

©2012 American Medical Association. All rights reserved.

Downloaded From: http://archinte.jamanetwork.com/ by a NHS Queen Elizabeth Hospital King's Lynn User on 04/21/2014

Fenton and colleagues1 followed more than 50 000 adultparticipants in the National Center for Health Statistics’Medical Expenditure Panel Survey over a 2-year period(longer for mortality). Judging from patients’ reportedsatisfaction with their physicians after year one, the au-thors found that, compared with patients in the lowestquartile of satisfaction, patients in the highest quartilewere subsequently less likely to be seen in an emergencydepartment, but more likely to be hospitalized, were re-sponsible for more prescription drug and total health careexpenditures, and were more likely to die. These relation-ships held after controlling for numerous potential con-founders, including year one health care utilization,health status, income, and health insurance.

The authors infer that efforts to cater to patient sat-isfaction may be ill guided; by implicitly encouraginghealth care providers to honor requests for (or to explic-itly offer) discretionary health care services, such ef-forts may lead to overutilization, higher costs, and worseoutcomes.

There is, however, reason to question the validity ofthe inference. One of the primary findings itself raisesconcern—a 26% mortality excess among the most sat-isfied patients, an effect size that far exceeds that for allother, more immediate, study outcomes (eg, a 12% ex-cess in hospitalizations). While the authors have at-tempted to separate patient satisfaction from correlates(eg, older age, more comorbidities) that might insteadbe responsible for higher utilization and worse out-comes, the likelihood of an unmeasured confounder re-mains high. One nomination is that a patient’s strong senseof connection to the health care system, related perhapsto (unmeasured) vulnerability or frailty, might predictmore satisfaction, hospitalization, and death.

And yet the inference is entirely believable—and causefor concern. The direct relationship between customersatisfaction and subsequent consumption is doctrine incommerce and business.2 “The customer is always right,”a phrase likely coined by Marshall Field, the depart-ment store magnate, in the late 19th century,3 is a credothat we, as consumers, may wish we encountered moreoften. Is health care any different?

Apparently not.But it should be.While most Americans may accurately assess how well

their washing machines, their hairdressers, or even theirairlines are performing, their evaluations of physiciansand health care interventions may have limited validity.

A dozen years ago, the New Yorker published a won-derful personal reflection by Joseph Epstein.4 Subtitled“A Healthy Man’s Nightmare,” it recounts the author’sjourney from a healthy, health conscious, and physi-cally active 62-year-old literature professor to a survi-vor of coronary artery bypass surgery (“a brutal piece ofwork”), weakened, with a lasting sense of vulnerabilitythat he eloquently labels “heart-consciousness.”4 He won-ders, one year afterwards, whether he will ever return tohis previous sense of well-being. Epstein’s journey startedwith a “routine” physical—his gift to his wife on the oc-casion of his 60th birthday—that revealed a low high-density lipoprotein cholesterol level, which in turn leddirectly to a stress test. Even more remarkable than the

journey is the author’s conclusion: he considers himselflucky, attributing his good fortune to his physicians, para-gons of excellence.

Regardless of whether one believes Mr Epstein to havebeen ultimately helped or harmed by his screening stresstest, his satisfaction with the experience should perhapsnot be as surprising as I initially found it. Satisfaction withseemingly adverse outcomes of potentially excessive medi-cal care appears to be the norm. Numerous studies havefound that patients are consistently highly satisfied withone of the most common downsides of medical care—false-positive test results and the downstream events thatfollow.5,6 Moreover, such patients are more likely to un-dergo the same (and likely other) testing in the future,dismissing their anxiety and other adverse effects as a neg-ligible price for a good outcome.

The same heuristic operates on the physician. Ran-sohoff et al7 proposed, a decade ago, that prostate-specific antigen (PSA) screening for prostate cancer ex-emplifies a system without negative feedback. Regardlessof the true net effect (beneficial or harmful) of screen-ing, a physician ordering a screening PSA receives a fa-vorable result: he can reassure the patient with a normalPSA result; celebrate with the patient who has over-come a false positive; or (most compelling for the phy-sician) offer potentially life-saving treatment to the pa-tient whose prostate cancer was “caught early”—notwithstanding the likelihood that the patient’s outcomemay be worse because of early detection. Regardless, thephysician can feel satisfied, and more certain that order-ing the next screening PSA will be the right decision,which will then appear to be the case, and so on.

Positive feedback systems abound in health care,for both physicians and patients. Diagnostically,almost any unnecessary, or discretionary, test (par-ticularly imaging) has a good chance of detecting anabnormality. Acting on that abnormality has an excel-lent chance of producing a favorable outcome (be-cause a good outcome was already highly likely). Hav-ing obtained an excellent outcome, ostensibly owingto a test that was seemingly unnecessary, a naturalreaction would be thereafter to perform (or, forpatients, undergo) even more discretionary testing inpatients with an increasingly negligible likelihood ofbenefit—and greater risk of net harm.

Consider thyroid cancer: incidence of papillary car-cinoma (by far the most common type) has tripled overa 30-year period, with an abundance of very small can-cers that appear nonlethal.8 The excess cases almost cer-tainly represent pseudodisease (destined never to causesymptoms during a patient’s lifetime)—patients who can-not possibly benefit from having had their cancer de-tected, but can be, and likely are, harmed. However, inthe eyes of the patient, her loved ones (and casual ac-quaintances), and her physicians, she was snatched fromthe jaws of a premature death by a vigilant physician whothought he felt something on examination or who inex-plicably ordered a thyroid ultrasound examination. Thelesson learned, for all, will surely be to be increasinglyvigilant in the future.

Ransohoff et al7(p665) explains, “The point is that . . . de-cisions for aggressive intervention—screening or treat-

ARCH INTERN MED/ VOL 172 (NO. 5), MAR 12, 2012 WWW.ARCHINTERNMED.COM412

©2012 American Medical Association. All rights reserved.

Downloaded From: http://archinte.jamanetwork.com/ by a NHS Queen Elizabeth Hospital King's Lynn User on 04/21/2014

ment—may be positively reinforced when patients andphysicians view the decisions from the perspective of anindividual person.”

Even if patients and physicians were to see throughthis illusion, overcoming the “more is always better” fal-lacy of health care remains an enormous challenge. In arecent survey published in the Archives,9 we found thatnearly half of US primary care physicians believed thattheir own patients were receiving too much medical care,and they identified potent systemic incentives encour-aging aggressive practice. Practicing physicians havelearned—from reimbursement systems, the medical li-ability environment, and clinical performance scorekeep-ers—that they will be rewarded for excess and penalizedif they risk not doing enough.

More aggressive practice, therefore, improves not onlypatients’ perceived outcomes, but also those of physi-cians (reimbursement, performance ratings, protectionagainst lawsuits), and the positive feedback loop of healthcare utilization is fueled at two ends.

As any engineer will tell you (and as my father, an ap-plied mathematician, wanted to make sure I understoodas he read this over my shoulder during our tropical va-cation), a positive feedback system is not in fact positive(ie, favorable)—it represents an unstable system, one thatcannot control its own growth, or demise. We, as a pro-fession and as a society, can take responsibility for con-trolling this unrestrained system only if we commit toovercoming the widespread misconception that more careis necessarily better care, and to realigning the incen-tives that help nurture this belief.

Published Online: February 13, 2012. doi:10.1001/archinternmed.2012.62

Author Affiliations: Department of Veterans Affairs Medi-cal Center, VA Outcomes Group, White River Junction,Vermont, and The Dartmouth Institute for Health Policyand Clinical Practice, Lebanon, New Hampshire.Correspondence: Dr Sirovich, Department of VeteransAffairs Medical Center, VA Outcomes Group (111B), 215N Main St, White River Junction, VT 05009 (brenda.sirovich@dartmouth.edu).Financial Disclosure: None reported.Disclaimer: The views expressed herein do not neces-sarily represent the views of the Department of VeteransAffairs or the US government.Online-Only Material: Visit http://www.archinternmed.com to listen to an author interview about this article.Additional Information: Nathaniel Hochman, BA, MSc,provided valuable comments on an earlier draft of thisInvited Commentary.

1. Fenton JJ, Jerant AF, Bertakis KD, Franks P. The cost of satisfaction: a na-tional study of patient satisfaction, health care utilization, expenditures, andmortality [published online February 13, 2012]. Arch Intern Med. 2012;172(5):405-411.

2. Seiders K, Voss GB, Grewal D, Godfrey AL. Do satisfied customers buy more?examining moderating influences in a retailing context. J Mark. 2005;69(4):26-43.

3. The Phrase Finder. The customer is always right. http://www.phrases.org.uk/meanings/106700.html. Accessed December 24, 2011.

4. Epstein J. Taking the bypass: a healthy man’s nightmare. New Yorker. April12, 1999;75:58-63.

5. McGovern PM, Gross CR, Krueger RA, Engelhard DA, Cordes JE, ChurchTR. False-positive cancer screens and health-related quality of life. Cancer Nurs.2004;27(5):347-352.

6. Pisano ED, Earp J, Schell M, Vokaty K, Denham A. Screening behavior of womenafter a false-positive mammogram. Radiology. 1998;208(1):245-249.

7. Ransohoff DF, McNaughton Collins M, Fowler FJ. Why is prostate cancer screen-ing so common when the evidence is so uncertain? a system without nega-tive feedback. Am J Med. 2002;113(8):663-667.

8. Davies L, Welch HG. Increasing incidence of thyroid cancer in the UnitedStates, 1973-2002. JAMA. 2006;295(18):2164-2167.

9. Sirovich BE, Woloshin S, Schwartz LM. Too little? too much? primary carephysicians’ views on US health care: a brief report. Arch Intern Med. 2011;171(17):1582-1585.

Brenda E. Sirovich, MD, MS

ARCH INTERN MED/ VOL 172 (NO. 5), MAR 12, 2012 WWW.ARCHINTERNMED.COM413

©2012 American Medical Association. All rights reserved.

Downloaded From: http://archinte.jamanetwork.com/ by a NHS Queen Elizabeth Hospital King's Lynn User on 04/21/2014