Medical practice variations: changing the theoretical approach

Abstract

Variations in medical practice are well documented, but there has been less progress in explaining these variations. This paper discusses the existing theories and hypotheses and concludes that a change in theoretical approach is required, to one that more directly highlights the social context influencing the behaviour of doctors in their daily practice. An initial alternative model for explaining variation in practice style is presented. The paper illustrates how (combinations of) important structural factors, such as the availability of hospital resources, the way the doctor is reimbursed, the availability of patients, professional uncertainty, and the way the hospital is financed, lead to hypotheses about when different local standards of medical care emerge. It is concluded that theoretical progress in research on variations in medical practice is possible and that empirical research needs to be driven by hypotheses that emphasize the role of social contexts in the doctor's decision behaviour. Some suggestions for future lines of research are outlined.

Mutual influences of general practitioners in partnerships

“…Peer review is increasingly part of normal routine in medical partnerships. Doctors risk losing social approval if their medical performance is criticised by their colleagues (Westert, 1996;Westert & Groenewegen, 1999). When people evaluate their own personal skills or self-image, they rely on role equivalents (Burkhardt, 1994).…”

Variation in Hospital Length of Stay: Do Physicians Adapt Their Length of Stay Decisions to What Is Usual in the Hospital Where They Work?

“…Several further possible explanations remain for the patterns of variation within work environments. It may be that physicians adapt to the colleagues they work with--that they follow the pack as Eddy (1984) called it--or that there is another factor in the work environment, such as hospital management or the availability of beds and facilities (Westert 1992;Westert and Groenewegen 1999;Kroneman 2001), which influences their medical choices.…”

“…Similarities of practice styles within the same social context, practice style changes with changes in the social context Westert (1992) and Westert and Groenewegen (1999) consequence of attitude and belief change is a gradual process. Other explanations for similar behavior are selection and adaptation to the circumstances under which physicians work (de Jong, Groenewegen, and Westert 2003).…”

“…Physicians expected to show similar behavior will be selected by the hospital management or by colleagues. If this strategy is followed, local standards of medical care come into being within medical teams that share the same work environment (Westert and Groenewegen 1999). Whether local standards come into being or not, might depend on the extent to which the physicians working in a hospital form a social group, and are able to develop into a normative community.…”

“…The ''surgical signature'' and enthusiasm hypotheses assume that physicians have a preference for certain procedures, but the behavioral mechanisms that produce different practice styles remain unclear. Westert and Groenewegen (1999) offered an alternative to this preference-centered approach, emphasizing incentives and environmental conditions that influence the behavior of physicians by providing opportunities and constraints. Westert (1992) applied this approach in a model of local standards that predicts similarities among physicians who share a common work environment and thus a social system and similar constraints.…”