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Expensive services are more likely to be affected by this type of incentive than inexpensive preventive services. Salary compensation plans pay physicians the same regardless of the amount of clinical work performed. The incentive here is to see fewer patients. In summary, expert clinical decision-making can be appreciated as a complex interplay between cognitive devices used to simplify large amounts of complex information interacting with physician biases reﬂecting education, training, and experience, all of which are shaped by powerful, sometimes perverse, external forces.
An important aspect of patient care involves an appreciation of the “quality of life,” a subjective assessment of what each patient values most. Such an assessment requires detailed, sometimes intimate knowledge of the patient, which can usually be obtained only through deliberate, unhurried, and often repeated conversations. It is in these situations that the time constraints of a managed-care setting may prove particularly problematic. Time pressures will always threaten these interactions but do not diminish the importance of understanding patients’ priorities from their point of view.
Factors that inﬂuence this role include the physician’s knowledge, training, and experience. It is obvious that physicians cannot practice evidence-based medicine (EBM; described later in the chapter) if they are unfamiliar with the evidence. As would be expected, specialists generally know the evidence in their ﬁeld better than do generalists. Surgeons may be more enthusiastic about recommending surgery than medical doctors because their belief in the beneﬁcial effects of surgery is stronger. For the same reason, invasive cardiologists are much more likely to refer chest pain patients for diagnostic catheterization than are noninvasive cardiologists or generalists.