Stephen J. Spann, MD

Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad array of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.¹

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.² Wagner and colleagues³ believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.

Health care in the 21st century

Many forces are reshaping the way health care will be delivered in the United States in this century.⁴ Both the purchasers and the consumers of health care are demanding evidence of quality, while the drive to contain spiraling costs continues. Growing consumerism is resulting in patient demands for better (ie, quicker) access to care and better service from providers. These new consumers are looking for choice among providers. They are demanding more and better information about their health and more participation in decision making about their care. They are becoming sophisticated in the use of the Internet, gaining experience with e-commerce and expecting to gain access to health information, provider appointments, their medical records, and their physicians through e-health applications. There is a growing emphasis on improving the prevention of disease and the management of chronic illnesses. There is more attention to the health of populations of patients and entire communities. There is also a federal government campaign underway to reduce the errors in health care and improve patient safety.

Redesigning family practice

Since the current family practice model is under threat and health care is being reshaped at a rapid pace, family practice must be redesigned for it to survive. What role will the family physician have in the evolving health care system? Morrison⁵ anticipates that physicians are likely to perform 6 core functions in the new medical care system: clinical data collector, shaman, health advisor and wellness coach, knowledge navigator, proceduralist, and diagnostician.

Although diagnostic technologies will continue to evolve and enhance our abilities to detect disease, the patient’s history will continue to be our most important diagnostic tool for the foreseeable future. Despite the expanding armamentarium of therapeutic technologies, the physician’s role as healer will continue to be paramount. The physician-patient relationship that is the cornerstone of family practice will continue to be our most powerful therapeutic tool. Health behavior and lifestyle modification will assume more importance as a way of preventing and treating chronic diseases. Family physicians will need to become experts in helping their patients eat better, exercise more, and avoid using noxious substances. Patients and families will have more access to health care information through the Internet and will need help and guidance in managing, interpreting, and customizing that information. Family physicians will need to know how to harness the power of these tools to better serve their patients. Evolving medical technology will introduce new diagnostic and therapeutic procedures into medical practice. Some of these will be disruptive: simpler, less invasive, and more cost-effective than the technologies they replace.⁶ Family physicians should seize these disruptive technologies and implement them in their practices, improving the quality and cost-effectiveness of their care. Advances in information technology will enhance the physician’s ability to make more accurate diagnoses on the basis of available diagnostic test inputs. Electronic medical records (EMRs) that are linked to clinical data repositories, expert systems based on neural networks, and just-in-time information systems available at the point of care will significantly improve the family physician’s diagnostic acumen.

How will the family practice of the future need to be structured and function to be successful? An EMR will serve as the practice’s central nervous system, handling many of the complex information management tasks inherent in primary care medical practice. Registries of patients with chronic diseases linked to physician prompt and patient reminder systems will enhance evidence-based disease state management in the practice. Process and outcomes of care evaluations will be carried out through electronic audit of EMR-linked clinical data repositories. Patient care will be rendered by an integrated multidisciplinary health care team that optimizes the use of each team member’s skills. The family physician will coordinate and direct the team’s work, leveraging her time and expertise through a collaborative model of practice. An open-access appointment system will allow patients to receive care when they want and need it. Group visits will provide more efficient care and a means of mutual support between patients. Patients will be able to communicate asynchronously with the practice through the use of a secure Internet portal and E-mail to make appointments, receive laboratory and imaging study results, request prescription refills, report self-monitoring data such as blood pressures and blood sugars, access their own medical records, ask questions about their health and health care, use decision support systems to allow them to share in important decisions about their care, and pay their bills. Family practice offices will have highly standardized and efficient processes and work flows that minimize waste, eliminate backlog, and allow the health care team to do today’s work today.⁷ Family physicians will have ready access to just-in-time information systems that will provide evidence-based answers to the majority of their clinical questions within 60 seconds, essentially eliminating the need to refer patients because of insufficient knowledge or experience.

Overcoming barriers

Much of the needed information technology and most of the know-how regarding the clinical process redesign needed to make this vision a reality exist today. However, it is practically impossible for small or even large group family practices to aspire to such a model of care in today’s economic environment. A new business model is needed that can bring together software and hardware vendors, application service providers, and clinical management and redesign expertise and package a series of turnkey products and services that are accessible and affordable even to small group family practices. The model could take the form of a franchise or perhaps a cooperative, funded through private investment, or the federal government could subsidize the development of this package, insuring its availability at a low cost to physician users. The new model should allow family physicians to maintain ownership of their practices, while redesigning the way they provide care to their patients. The development and implementation of such a model is critical to the survival of our specialty.

All correspondence should be addressed to Stephen J. Spann, MD, Professor and Chairman, Department of Family and Community Medicine, Baylor College of Medicine, 5510 Greenbriar, Houston, TX 77005. E-mail: [email protected].

Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad array of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.¹

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.² Wagner and colleagues³ believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.

Health care in the 21st century

Many forces are reshaping the way health care will be delivered in the United States in this century.⁴ Both the purchasers and the consumers of health care are demanding evidence of quality, while the drive to contain spiraling costs continues. Growing consumerism is resulting in patient demands for better (ie, quicker) access to care and better service from providers. These new consumers are looking for choice among providers. They are demanding more and better information about their health and more participation in decision making about their care. They are becoming sophisticated in the use of the Internet, gaining experience with e-commerce and expecting to gain access to health information, provider appointments, their medical records, and their physicians through e-health applications. There is a growing emphasis on improving the prevention of disease and the management of chronic illnesses. There is more attention to the health of populations of patients and entire communities. There is also a federal government campaign underway to reduce the errors in health care and improve patient safety.

Redesigning family practice

Since the current family practice model is under threat and health care is being reshaped at a rapid pace, family practice must be redesigned for it to survive. What role will the family physician have in the evolving health care system? Morrison⁵ anticipates that physicians are likely to perform 6 core functions in the new medical care system: clinical data collector, shaman, health advisor and wellness coach, knowledge navigator, proceduralist, and diagnostician.

Although diagnostic technologies will continue to evolve and enhance our abilities to detect disease, the patient’s history will continue to be our most important diagnostic tool for the foreseeable future. Despite the expanding armamentarium of therapeutic technologies, the physician’s role as healer will continue to be paramount. The physician-patient relationship that is the cornerstone of family practice will continue to be our most powerful therapeutic tool. Health behavior and lifestyle modification will assume more importance as a way of preventing and treating chronic diseases. Family physicians will need to become experts in helping their patients eat better, exercise more, and avoid using noxious substances. Patients and families will have more access to health care information through the Internet and will need help and guidance in managing, interpreting, and customizing that information. Family physicians will need to know how to harness the power of these tools to better serve their patients. Evolving medical technology will introduce new diagnostic and therapeutic procedures into medical practice. Some of these will be disruptive: simpler, less invasive, and more cost-effective than the technologies they replace.⁶ Family physicians should seize these disruptive technologies and implement them in their practices, improving the quality and cost-effectiveness of their care. Advances in information technology will enhance the physician’s ability to make more accurate diagnoses on the basis of available diagnostic test inputs. Electronic medical records (EMRs) that are linked to clinical data repositories, expert systems based on neural networks, and just-in-time information systems available at the point of care will significantly improve the family physician’s diagnostic acumen.

How will the family practice of the future need to be structured and function to be successful? An EMR will serve as the practice’s central nervous system, handling many of the complex information management tasks inherent in primary care medical practice. Registries of patients with chronic diseases linked to physician prompt and patient reminder systems will enhance evidence-based disease state management in the practice. Process and outcomes of care evaluations will be carried out through electronic audit of EMR-linked clinical data repositories. Patient care will be rendered by an integrated multidisciplinary health care team that optimizes the use of each team member’s skills. The family physician will coordinate and direct the team’s work, leveraging her time and expertise through a collaborative model of practice. An open-access appointment system will allow patients to receive care when they want and need it. Group visits will provide more efficient care and a means of mutual support between patients. Patients will be able to communicate asynchronously with the practice through the use of a secure Internet portal and E-mail to make appointments, receive laboratory and imaging study results, request prescription refills, report self-monitoring data such as blood pressures and blood sugars, access their own medical records, ask questions about their health and health care, use decision support systems to allow them to share in important decisions about their care, and pay their bills. Family practice offices will have highly standardized and efficient processes and work flows that minimize waste, eliminate backlog, and allow the health care team to do today’s work today.⁷ Family physicians will have ready access to just-in-time information systems that will provide evidence-based answers to the majority of their clinical questions within 60 seconds, essentially eliminating the need to refer patients because of insufficient knowledge or experience.

Overcoming barriers

Much of the needed information technology and most of the know-how regarding the clinical process redesign needed to make this vision a reality exist today. However, it is practically impossible for small or even large group family practices to aspire to such a model of care in today’s economic environment. A new business model is needed that can bring together software and hardware vendors, application service providers, and clinical management and redesign expertise and package a series of turnkey products and services that are accessible and affordable even to small group family practices. The model could take the form of a franchise or perhaps a cooperative, funded through private investment, or the federal government could subsidize the development of this package, insuring its availability at a low cost to physician users. The new model should allow family physicians to maintain ownership of their practices, while redesigning the way they provide care to their patients. The development and implementation of such a model is critical to the survival of our specialty.

All correspondence should be addressed to Stephen J. Spann, MD, Professor and Chairman, Department of Family and Community Medicine, Baylor College of Medicine, 5510 Greenbriar, Houston, TX 77005. E-mail: [email protected].

Family practice in the United States is under threat. Patient demand for direct access to specialists is growing, which reflects the population’s insatiable appetite for high-technology medicine and may also be indicative of a backlash against the gatekeeper model imposed by managed care. The hospitalist movement is further removing family physicians from the inpatient care setting. The number of advanced nurse practitioners and physicians’ assistants claiming to deliver primary medical care of equivalent quality to and lower cost than family physicians is also growing. Patients also have ready access to a broad array of health and medical care information services through the Internet, which may provide the opportunity for them to decide what kind of specialized medical care they need.

Many managed care organizations (MCOs) have instituted demand management programs that give patients direct access to telephone triage centers staffed by nurses 24 hours. MCOs have also instituted chronic disease management programs for managing patients with specific chronic diseases (diabetes, asthma, heart failure) in a more cost-effective manner, often “carving out” that part of their care away from the primary care physician.¹

There are more and more published studies that purport to show that the outcomes of care for patients with certain chronic diseases are better when provided by specialists compared with generalist physicians.² Wagner and colleagues³ believe that improved outcomes of care by specialists are probably related to better-organized processes of care and not necessarily to superior specialist knowledge or expertise. They note that studies comparing usual generalist care with usual specialist care have found no differences in care outcomes.

Family physicians find that their level of reimbursement is decreasing, while the amount of regulation, paperwork, and office overhead is increasing. They have to see more patients in less time to maintain their incomes. Sometimes feeling like hamsters on a wheel, they are becoming more dissatisfied with their practice. This is not going unnoticed by medical students; the number of US medical school graduates matching in family practice residency programs has declined for 4 years in a row. Family practice as we know and practice it today is in peril.

Health care in the 21st century

Many forces are reshaping the way health care will be delivered in the United States in this century.⁴ Both the purchasers and the consumers of health care are demanding evidence of quality, while the drive to contain spiraling costs continues. Growing consumerism is resulting in patient demands for better (ie, quicker) access to care and better service from providers. These new consumers are looking for choice among providers. They are demanding more and better information about their health and more participation in decision making about their care. They are becoming sophisticated in the use of the Internet, gaining experience with e-commerce and expecting to gain access to health information, provider appointments, their medical records, and their physicians through e-health applications. There is a growing emphasis on improving the prevention of disease and the management of chronic illnesses. There is more attention to the health of populations of patients and entire communities. There is also a federal government campaign underway to reduce the errors in health care and improve patient safety.

Redesigning family practice

Since the current family practice model is under threat and health care is being reshaped at a rapid pace, family practice must be redesigned for it to survive. What role will the family physician have in the evolving health care system? Morrison⁵ anticipates that physicians are likely to perform 6 core functions in the new medical care system: clinical data collector, shaman, health advisor and wellness coach, knowledge navigator, proceduralist, and diagnostician.

Although diagnostic technologies will continue to evolve and enhance our abilities to detect disease, the patient’s history will continue to be our most important diagnostic tool for the foreseeable future. Despite the expanding armamentarium of therapeutic technologies, the physician’s role as healer will continue to be paramount. The physician-patient relationship that is the cornerstone of family practice will continue to be our most powerful therapeutic tool. Health behavior and lifestyle modification will assume more importance as a way of preventing and treating chronic diseases. Family physicians will need to become experts in helping their patients eat better, exercise more, and avoid using noxious substances. Patients and families will have more access to health care information through the Internet and will need help and guidance in managing, interpreting, and customizing that information. Family physicians will need to know how to harness the power of these tools to better serve their patients. Evolving medical technology will introduce new diagnostic and therapeutic procedures into medical practice. Some of these will be disruptive: simpler, less invasive, and more cost-effective than the technologies they replace.⁶ Family physicians should seize these disruptive technologies and implement them in their practices, improving the quality and cost-effectiveness of their care. Advances in information technology will enhance the physician’s ability to make more accurate diagnoses on the basis of available diagnostic test inputs. Electronic medical records (EMRs) that are linked to clinical data repositories, expert systems based on neural networks, and just-in-time information systems available at the point of care will significantly improve the family physician’s diagnostic acumen.

How will the family practice of the future need to be structured and function to be successful? An EMR will serve as the practice’s central nervous system, handling many of the complex information management tasks inherent in primary care medical practice. Registries of patients with chronic diseases linked to physician prompt and patient reminder systems will enhance evidence-based disease state management in the practice. Process and outcomes of care evaluations will be carried out through electronic audit of EMR-linked clinical data repositories. Patient care will be rendered by an integrated multidisciplinary health care team that optimizes the use of each team member’s skills. The family physician will coordinate and direct the team’s work, leveraging her time and expertise through a collaborative model of practice. An open-access appointment system will allow patients to receive care when they want and need it. Group visits will provide more efficient care and a means of mutual support between patients. Patients will be able to communicate asynchronously with the practice through the use of a secure Internet portal and E-mail to make appointments, receive laboratory and imaging study results, request prescription refills, report self-monitoring data such as blood pressures and blood sugars, access their own medical records, ask questions about their health and health care, use decision support systems to allow them to share in important decisions about their care, and pay their bills. Family practice offices will have highly standardized and efficient processes and work flows that minimize waste, eliminate backlog, and allow the health care team to do today’s work today.⁷ Family physicians will have ready access to just-in-time information systems that will provide evidence-based answers to the majority of their clinical questions within 60 seconds, essentially eliminating the need to refer patients because of insufficient knowledge or experience.

Overcoming barriers

Much of the needed information technology and most of the know-how regarding the clinical process redesign needed to make this vision a reality exist today. However, it is practically impossible for small or even large group family practices to aspire to such a model of care in today’s economic environment. A new business model is needed that can bring together software and hardware vendors, application service providers, and clinical management and redesign expertise and package a series of turnkey products and services that are accessible and affordable even to small group family practices. The model could take the form of a franchise or perhaps a cooperative, funded through private investment, or the federal government could subsidize the development of this package, insuring its availability at a low cost to physician users. The new model should allow family physicians to maintain ownership of their practices, while redesigning the way they provide care to their patients. The development and implementation of such a model is critical to the survival of our specialty.

All correspondence should be addressed to Stephen J. Spann, MD, Professor and Chairman, Department of Family and Community Medicine, Baylor College of Medicine, 5510 Greenbriar, Houston, TX 77005. E-mail: [email protected].

The paper by Fiscella and colleagues¹ in this issue of the Journal is an important addition to the literature on the variations in medical care provided by family physicians and general internists. This careful study documents, as have many others, that the care provided by family physicians is less costly than that provided by general internists. Its new contribution is the finding that interspecialty differences in risk aversion are predictive of differences in resource utilization. Previous studies have shown that physicians who are more risk averse are more likely to order diagnostic tests, refer to specialists, hospitalize, and generate higher overall costs. The study by Fiscella and colleagues suggests that some of the difference in medical care resource utilization between family physicians and internists may be explained by psychological differences in risk aversion. What are some of the other factors that may contribute to the difference in resource utilization between physicians in these 2 primary care specialties? Why are general internists more risk averse than their family physician counterparts?

The threshold approach to clinical decision making first described by Pauker and Kassirer² is a useful conceptual framework for thinking about variations in physician decision making and medical resource utilization. For a given disease (D), for which there is a given treatment and a given diagnostic test, this model prescribes a no treatment-test threshold (P1) and a test-treatment threshold (P2). If the patient’s probability of disease, P(D), is less than P1, then the model prescribes that the patient should not be tested or treated; if P(D) is greater than P2, then the patient should not be tested but simply treated. If P(D) is greater than P1 but less than P2, then the diagnostic test should be performed. The optimal P1 and P2 thresholds can be determined using decision analysis, taking into account the costs, risks, and benefits of these 3 strategies. A large number of variables must be included in the decision tree, such as the efficacy of treatment and the placebo effect; the probability of treatment side effects; the sensitivity and specificity of the test; the outcomes of treated disease, untreated disease, and treatment side effects; and the costs of tests, treatment, and adverse outcomes of disease and treatment. Although these kinds of analyses have been published for some combinations of diseases, treatments, and tests,³ physicians often make these decisions using subjective threshold estimates and subjective estimates of disease probability based on personal experience.

Variability in physicians’ subjective estimates of the P1 and P2 thresholds,^4-5 along with variability in subjective estimates of disease probability,⁶ may explain a significant amount of the variation in physician decision making and resource utilization.⁷ Physician discomfort with uncertainty and risk aversion may well have a significant unconscious effect on subjective P1 and P2 threshold estimation. The anticipated effect would be to lower the probability of disease at which it is acceptable not to treat or test (P1) and to increase the probability of disease at which it is acceptable to treat without testing (P2). A risk averse physician, therefore, would be more likely to test before deciding to do nothing or to treat, increasing the use of diagnostic and consultant resources.

Physician training may also have an impact on threshold estimation. Internists spend much more of their training time in the inpatient setting than family physicians. They are schooled in the art of differential diagnosis and the importance of ruling out possible, though unlikely, diagnoses. Family physicians are typically taught that common things are common. This could mean that internists subjectively set the P1 threshold lower and the P2 threshold higher, so they are more likely to test for unlikely diagnoses than family physicians.

The threshold approach prescribes a patient management strategy based on the physician’s subjective estimate of the patient’s probability of disease. An underestimation of the probability of a likely disease would result in unnecessary testing, as would an overestimation of the probability of an unlikely disease. A general internist trained mostly in a tertiary care setting would be more likely to underestimate the probability of common diseases and overestimate the probability of uncommon diseases than a family physician trained mostly in a primary care setting.

Questions For Future Research

There are many unanswered questions regarding the difference in medical care resource utilization between general internists and family physicians. Are there systematic differences between no treatment-test and test-treatment threshold estimates for various diseases between family physicians and general internists? Are there systematic differences in subjective estimates of disease probability? How much of the difference in resource utilization relates to the personality traits of persons who choose each specialty? How much is because of differences in learned approaches to differential diagnosis and clinical problem solving, and how much is due to experiences in caring for different populations of patients? Is risk aversion a personality trait that a physician brings to training, or is it a behavior that is learned during training? If it is a personality trait, can it be modified? If it is a learned behavior, can it be unlearned? Do physicians trained in community-based residency programs use fewer medical care resources than physicians trained in university-based programs? Do general internists trained in primary care tracks use fewer resources than those trained in traditional tracks? These questions provide significant opportunities for future research on this subject.

The paper by Fiscella and colleagues¹ in this issue of the Journal is an important addition to the literature on the variations in medical care provided by family physicians and general internists. This careful study documents, as have many others, that the care provided by family physicians is less costly than that provided by general internists. Its new contribution is the finding that interspecialty differences in risk aversion are predictive of differences in resource utilization. Previous studies have shown that physicians who are more risk averse are more likely to order diagnostic tests, refer to specialists, hospitalize, and generate higher overall costs. The study by Fiscella and colleagues suggests that some of the difference in medical care resource utilization between family physicians and internists may be explained by psychological differences in risk aversion. What are some of the other factors that may contribute to the difference in resource utilization between physicians in these 2 primary care specialties? Why are general internists more risk averse than their family physician counterparts?

The threshold approach to clinical decision making first described by Pauker and Kassirer² is a useful conceptual framework for thinking about variations in physician decision making and medical resource utilization. For a given disease (D), for which there is a given treatment and a given diagnostic test, this model prescribes a no treatment-test threshold (P1) and a test-treatment threshold (P2). If the patient’s probability of disease, P(D), is less than P1, then the model prescribes that the patient should not be tested or treated; if P(D) is greater than P2, then the patient should not be tested but simply treated. If P(D) is greater than P1 but less than P2, then the diagnostic test should be performed. The optimal P1 and P2 thresholds can be determined using decision analysis, taking into account the costs, risks, and benefits of these 3 strategies. A large number of variables must be included in the decision tree, such as the efficacy of treatment and the placebo effect; the probability of treatment side effects; the sensitivity and specificity of the test; the outcomes of treated disease, untreated disease, and treatment side effects; and the costs of tests, treatment, and adverse outcomes of disease and treatment. Although these kinds of analyses have been published for some combinations of diseases, treatments, and tests,³ physicians often make these decisions using subjective threshold estimates and subjective estimates of disease probability based on personal experience.

Variability in physicians’ subjective estimates of the P1 and P2 thresholds,^4-5 along with variability in subjective estimates of disease probability,⁶ may explain a significant amount of the variation in physician decision making and resource utilization.⁷ Physician discomfort with uncertainty and risk aversion may well have a significant unconscious effect on subjective P1 and P2 threshold estimation. The anticipated effect would be to lower the probability of disease at which it is acceptable not to treat or test (P1) and to increase the probability of disease at which it is acceptable to treat without testing (P2). A risk averse physician, therefore, would be more likely to test before deciding to do nothing or to treat, increasing the use of diagnostic and consultant resources.

Physician training may also have an impact on threshold estimation. Internists spend much more of their training time in the inpatient setting than family physicians. They are schooled in the art of differential diagnosis and the importance of ruling out possible, though unlikely, diagnoses. Family physicians are typically taught that common things are common. This could mean that internists subjectively set the P1 threshold lower and the P2 threshold higher, so they are more likely to test for unlikely diagnoses than family physicians.

The threshold approach prescribes a patient management strategy based on the physician’s subjective estimate of the patient’s probability of disease. An underestimation of the probability of a likely disease would result in unnecessary testing, as would an overestimation of the probability of an unlikely disease. A general internist trained mostly in a tertiary care setting would be more likely to underestimate the probability of common diseases and overestimate the probability of uncommon diseases than a family physician trained mostly in a primary care setting.

Questions For Future Research

There are many unanswered questions regarding the difference in medical care resource utilization between general internists and family physicians. Are there systematic differences between no treatment-test and test-treatment threshold estimates for various diseases between family physicians and general internists? Are there systematic differences in subjective estimates of disease probability? How much of the difference in resource utilization relates to the personality traits of persons who choose each specialty? How much is because of differences in learned approaches to differential diagnosis and clinical problem solving, and how much is due to experiences in caring for different populations of patients? Is risk aversion a personality trait that a physician brings to training, or is it a behavior that is learned during training? If it is a personality trait, can it be modified? If it is a learned behavior, can it be unlearned? Do physicians trained in community-based residency programs use fewer medical care resources than physicians trained in university-based programs? Do general internists trained in primary care tracks use fewer resources than those trained in traditional tracks? These questions provide significant opportunities for future research on this subject.

The paper by Fiscella and colleagues¹ in this issue of the Journal is an important addition to the literature on the variations in medical care provided by family physicians and general internists. This careful study documents, as have many others, that the care provided by family physicians is less costly than that provided by general internists. Its new contribution is the finding that interspecialty differences in risk aversion are predictive of differences in resource utilization. Previous studies have shown that physicians who are more risk averse are more likely to order diagnostic tests, refer to specialists, hospitalize, and generate higher overall costs. The study by Fiscella and colleagues suggests that some of the difference in medical care resource utilization between family physicians and internists may be explained by psychological differences in risk aversion. What are some of the other factors that may contribute to the difference in resource utilization between physicians in these 2 primary care specialties? Why are general internists more risk averse than their family physician counterparts?

The threshold approach to clinical decision making first described by Pauker and Kassirer² is a useful conceptual framework for thinking about variations in physician decision making and medical resource utilization. For a given disease (D), for which there is a given treatment and a given diagnostic test, this model prescribes a no treatment-test threshold (P1) and a test-treatment threshold (P2). If the patient’s probability of disease, P(D), is less than P1, then the model prescribes that the patient should not be tested or treated; if P(D) is greater than P2, then the patient should not be tested but simply treated. If P(D) is greater than P1 but less than P2, then the diagnostic test should be performed. The optimal P1 and P2 thresholds can be determined using decision analysis, taking into account the costs, risks, and benefits of these 3 strategies. A large number of variables must be included in the decision tree, such as the efficacy of treatment and the placebo effect; the probability of treatment side effects; the sensitivity and specificity of the test; the outcomes of treated disease, untreated disease, and treatment side effects; and the costs of tests, treatment, and adverse outcomes of disease and treatment. Although these kinds of analyses have been published for some combinations of diseases, treatments, and tests,³ physicians often make these decisions using subjective threshold estimates and subjective estimates of disease probability based on personal experience.

Variability in physicians’ subjective estimates of the P1 and P2 thresholds,^4-5 along with variability in subjective estimates of disease probability,⁶ may explain a significant amount of the variation in physician decision making and resource utilization.⁷ Physician discomfort with uncertainty and risk aversion may well have a significant unconscious effect on subjective P1 and P2 threshold estimation. The anticipated effect would be to lower the probability of disease at which it is acceptable not to treat or test (P1) and to increase the probability of disease at which it is acceptable to treat without testing (P2). A risk averse physician, therefore, would be more likely to test before deciding to do nothing or to treat, increasing the use of diagnostic and consultant resources.

Physician training may also have an impact on threshold estimation. Internists spend much more of their training time in the inpatient setting than family physicians. They are schooled in the art of differential diagnosis and the importance of ruling out possible, though unlikely, diagnoses. Family physicians are typically taught that common things are common. This could mean that internists subjectively set the P1 threshold lower and the P2 threshold higher, so they are more likely to test for unlikely diagnoses than family physicians.

The threshold approach prescribes a patient management strategy based on the physician’s subjective estimate of the patient’s probability of disease. An underestimation of the probability of a likely disease would result in unnecessary testing, as would an overestimation of the probability of an unlikely disease. A general internist trained mostly in a tertiary care setting would be more likely to underestimate the probability of common diseases and overestimate the probability of uncommon diseases than a family physician trained mostly in a primary care setting.

Questions For Future Research

There are many unanswered questions regarding the difference in medical care resource utilization between general internists and family physicians. Are there systematic differences between no treatment-test and test-treatment threshold estimates for various diseases between family physicians and general internists? Are there systematic differences in subjective estimates of disease probability? How much of the difference in resource utilization relates to the personality traits of persons who choose each specialty? How much is because of differences in learned approaches to differential diagnosis and clinical problem solving, and how much is due to experiences in caring for different populations of patients? Is risk aversion a personality trait that a physician brings to training, or is it a behavior that is learned during training? If it is a personality trait, can it be modified? If it is a learned behavior, can it be unlearned? Do physicians trained in community-based residency programs use fewer medical care resources than physicians trained in university-based programs? Do general internists trained in primary care tracks use fewer resources than those trained in traditional tracks? These questions provide significant opportunities for future research on this subject.