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August 25, 2015

Nearly one in four doctors may be a 'cowboy' who likes to go rogue

Daily Briefing

    About one in four doctors have a "cowboy" approach to medicine, and they could be responsible for hundreds of billions of dollars in wasted health care spending, a new Harvard study suggests.

    The study was based on survey responses from about 600 cardiologists and 935 primary care physicians (PCPs).

    The authors defined 25% of the cardiologists and 22% of the PCPs as "cowboys" for consistently administering non-evidence-based treatment, and suggest that these doctors' decisions represent roughly 35% of end-of-life Medicare expenditures and 12% of overall Medicare spending. Altogether, cowboy doctors may represent about 2% of the nation's gross domestic product.

    According to study co-author David Cutler, a Harvard University economics professor, these physicians' beliefs in ineffective treatments could stem from a personal belief that they are "interventionists." He tells Harvard Magazine, "I think some doctors are saying: 'I just can't accept that this patient is dying and there's absolutely nothing I can do. I've got to do something.'"

    How to have the hardest talk in health care: The end-of-life conversation

    According to the data, cowboy doctors tend to cluster in southeastern states like Florida, are more likely to be general practitioners than specialists, and are more likely to be male.     

    The researchers also found a link between the presence of cowboy doctors and higher end-of-life care spending in any given region.

    Supporting evidence-based practice—are health systems doing a good job?

    Changing the current incentive system

    Based on the study findings, the researchers speculate that a lack of financial penalty, rather than a potential reward, is a main reason for "cowboy" actions.

    Cutler says that the current system does not encourage physicians to ask the right questions about whether a potential treatment will benefit a patient.

    Instead, cowboy physicians tend to ignore scientific evidence, says study co-author Jonathan Skinner, a professor of economics at Dartmouth College, while "relying on their own beliefs," forged over time.

    Skinner adds, "If doctors restrict themselves to performing what is evidence-based, we can save hundreds of billions of dollars a year."


    Elliot Fisher, a professor of health policy at Dartmouth—who was not involved in the study—says the research highlights a power discrepancy between patients and doctors, in which physicians tend to follow their own treatment ideas, leaving little room for patients to voice their opinion.

    But he adds that the shift toward value-based payment systems—including accountable care organizations—could help change that dynamic by steering providers away from being "cowboys" and toward delivering more evidence-based treatments (Zhang, Harvard Magazine, September-October 2015; Harvard Business School working paper, 2015).

    Four principles for supporting evidence-based practice


    In a pilot survey, we posed the following statement to 28 CMOs: "My organization has achieved broad cultural acceptance of evidence-based practice across the medical staff." In response, 75% of the CMOs indicated that EBP had achieved some measure of acceptance at their organization.

    Yet, despite the shift toward broad acceptance of EBP among medical staff, over half of physicians report not actually using guidelines day-to-day when they are available.

    This infographic outlines four principles you can use to support EBP at your organization, along with action steps to implement each one and pitfalls to avoid along the way.


    Want to know more? Our "Building Evidence-Based Organization" study can help you pinpoint organization-specific opportunities to accelerate the adoption of evidence-based practices and learn how to build a "culture of adherence" across the medical staff. Read it now.

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    1. Current ArticleNearly one in four doctors may be a 'cowboy' who likes to go rogue

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