Mercuri Mathew, Gafni Amiram
Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada.
Institute for the History and Philosophy of Science and Technology, University of Toronto, Toronto, Ontario, Canada.
J Eval Clin Pract. 2018 Feb;24(1):145-151. doi: 10.1111/jep.12770. Epub 2017 May 29.
RATIONALE, AIMS, AND OBJECTIVES: The physician is often implicated as an important cause of observed variations in health care service use. However, it is not clear if physician-related variation is problematic for patient care. This paper illustrates that observed physician-related variation is not necessarily unwarranted.
This is a narrative review.
Many studies have attributed observed variations to the physician, but little attention is given towards discriminating between those variations that exist for good reasons and those that are unwarranted. Two arguments can be made for why physician-related variation is unwarranted. The first posits that physician-related factors should not play a role in management of care decisions because such decisions should be driven by science (which is imagined to be definitive). The second considers the possibility of supplier-induced demand as a factor driving observed variations. We show that neither argument is sufficient to rule out that physician-related variations may be warranted. Furthermore, the claim that such variations are necessarily problematic for patients has yet to be substantiated empirically.
It is not enough to simply show that physician-related variation can exist-one must also show where it is unwarranted and what is the magnitude of unwarranted variations. Failure to show this can have significant implications on how we interpret and respond to observed variations. Improved measurement of the sources of variation, especially with respect to patient preferences and context, may help us start to disentangle physician-related variation that is desirable from that which is unwarranted.
原理、目的及目标：医生常被认为是医疗服务使用中观察到的差异的一个重要原因。然而，尚不清楚与医生相关的差异对患者护理是否存在问题。本文表明，观察到的与医生相关的差异不一定是不合理的。
这是一篇叙述性综述。
许多研究将观察到的差异归因于医生，但对于区分那些有充分理由存在的差异和那些不合理的差异却很少关注。关于为何与医生相关的差异是不合理的，有两种观点。第一种观点认为，与医生相关的因素在护理决策管理中不应起作用，因为此类决策应由科学驱动（科学被认为是确定无疑的）。第二种观点考虑了供应商诱导需求作为导致观察到的差异的一个因素的可能性。我们表明，这两种观点都不足以排除与医生相关的差异可能是合理的。此外，声称此类差异必然对患者有问题这一说法尚未得到实证证实。
仅仅表明与医生相关的差异可能存在是不够的——还必须表明差异在何处是不合理的以及不合理差异的程度有多大。未能做到这一点可能会对我们如何解释和应对观察到的差异产生重大影响。改进对差异来源的衡量，尤其是关于患者偏好和背景方面的衡量，可能有助于我们开始区分理想的与医生相关的差异和不合理的差异。
