Doctor Shopping: A Phenomenon of Many Themes

| December 1, 2012 | 0 Comments

by Randy A. Sansone, MD, and Lori A. Sansone, MD

Dr. R. Sansone is a professor in the Departments of Psychiatry and Internal Medicine at Wright State University School of Medicine in Dayton, Ohio, and Director of Psychiatry Education at Kettering Medical Center in Kettering, Ohio; Dr. L. Sansone is a family medicine physician (civilian) and Medical Director, Family Health Clinic, Wright-Patterson Medical Center in WPAFB, Ohio. The views and opinions expressed in this column are those of the authors and do not reflect the official policy or position of the United States Air Force, Department of Defense, or US government.

Innov Clin Neurosci. 2012;9(11–12):42–46

This ongoing column is dedicated to the challenging clinical interface between psychiatry and primary care—two fields that are inexorably linked.

Funding: There was no funding for the development and writing of this article.

Financial Disclosures: The authors have no conflicts of interest relevant to the content of this article.

Key Words: Doctor shopping, drug abuse, drug misuse, healthcare utilization

Abstract: Doctor shopping is defined as seeing multiple treatment providers, either during a single illness episode or to procure prescription medications illicitly. According to the available literature, prevalence rates of doctor shopping vary widely, from 6.3 to 56 percent. However, this variability is partially attributable to research methodology, including the study definition of doctor shopping as well as the patient sample. The reasons for doctor shopping are varied. Some patient explanations for this phenomenon relate to clinician factors, such as inconvenient office hours or locations, long waiting times, personal characteristics or qualities of the provider, and/or insufficient communication time between the patient and clinician. Some patient explanations relate to personal factors and include both illness factors (e.g., symptom persistence, lack of understanding or nonacceptance of the diagnosis or treatment) as well as psychological factors (e.g., somatization, prescription drug-seeking). Importantly, not all doctor shopping is driven by suspect motivations. Being aware of these various patient justifications for doctor shopping is important in understanding and managing these challenging patients in the clinical setting, whether they emerge in psychiatric or primary care environments.

Introduction

Doctor shopping is a phenomenon that entails patients seeing multiple clinicians. This patient behavior is typically associated with a negative connotation among treatment providers. Numerous office visits by patients may be related to either the same illness episode or to procure prescription drugs illicitly. In this edition of The Interface, we discuss the various definitions of doctor shopping, available data on prevalence rates, and physician and patient factors that might account for this intriguing phenomenon.

What is Doctor Shopping?

Doctor shopping entails the scheduling by patients of office visits with multiple clinicians for the same agenda, either for a continuing illness or to procure prescription drugs illicitly. As expected, the explicit definitions in the literature vary considerably, with a significant proportion focusing on a given illness episode. For example, Lo et al[1] define doctor shopping as the changing of doctors without a professional referral during the same illness episode. Hagihara et al[2] describe doctor shopping as consulting multiple doctors during the same illness period. Macpherson et al[3] define doctor shopping as patient contact with three or more care sites during a single illness. Pradel et al[4] describe doctor shopping as the simultaneous use of several physicians by a patient. Rouby et al[5] define doctor shopping as simultaneous consultation with several physicians during the same period.

In addition to the theme of visiting multiple clinicians, several American investigators have constricted the definition of doctor shopping to specifically address the seeking by patients of illicit prescription medications, especially controlled substances. In this regard, Lineberry and Bostwick[6] define doctor shopping as patient visits to multiple physicians simply to procure prescriptions. Hall et al[7] characterize doctor shopping as obtaining prescriptions for controlled substances from five or more clinicians during the preceding year. Shaffer and Moss[8] define doctor shopping as patient consultation with multiple physicians in a short time frame with the explicit intent to deceive them in order to obtain controlled substances.

Although the preceding definitions of doctor shopping indicate some variability, all entail the requirement that multiple providers are sought by the patient. Some definitions specify that multiple clinicians are consulted in the context of a single episode of illness whereas other definitions focus on the illicit motive of the patient, which in the extant literature is most often related to the procurement of high-risk prescriptions, particularly controlled substances.

Prevalence of Doctor Shopping

Depending partially on the study methodology, particularly the definition of doctor shopping used by investigators and the sample type, rates for doctor shopping in various patient samples vary from 6.3 to 56 percent.[1–3,9–11] To further detail these rates, Wang and Lin[9] examined patients with upper respiratory infections and reported rates for doctor shopping of 6.3 percent. In a Canadian study, Macpherson et al[3] examined the prevalence of patients visiting three or more different care sites during a single illness episode following a visit to the emergency department, and confirmed a rate for doctor shopping of 18 percent. In a Japanese study of 1,088 patients from a general medicine outpatient clinic, Sato et al10 utilized a self-report questionnaire and reported that 23 percent of participants acknowledged doctor shopping, which was defined in this study as visiting two or more medical facilities prior to the current appointment for the same medical complaint. In another study from Japan, Hagihara et al[2] examined 303 internal-medicine patients and reported that 27.7 percent engaged in doctor shopping, which was defined as consulting multiple doctors within the same illness episode. In a study from Hong Kong, Lo et al[1] surveyed patients being seen in outpatient medicine departments and estimated the prevalence of doctor shopping, defined as the changing of doctors without professional referral during the same illness episode, at 40 percent. Finally, Hassan et al[11] examined 442 family-medicine outpatients using face-to-face interviews and determined that 56 percent met their criteria for doctor shopping. Overall, findings indicate broad variability in the percentages of patients who doctor-shop. Again, these percentages may be partially moderated by investigators’ definition of doctor shopping, characteristics of the patient sample, and/or the study setting.

Explanations for Doctor Shopping

According to the existing literature, there are a number of reasons why patients engage in doctor shopping. We will divide these patient justifications into two general categories: physician-related factors and patient-related factors.

Physician-related factors. While the majority of studies has focused on patient factors related to doctor shopping, several studies have examined specific physician factors, as well. In this regard, Yeung et al[12] determined that extended waiting times contributed to doctor shopping among patients in a Hong Kong community medicine clinic. Feroni et al[13] reported that physician attitude, particularly being stringent, stern, or strict, was a factor in doctor shopping among French patients in buprenorphine maintenance programs. In a community sample from the United States, Kasteler et al[14] uncovered a number of physician factors related to patient doctor shopping. These factors included inconvenient office hours or locations, undesirable personal qualities of the physician, and insufficient time for communication between the clinician and patient.

Patient-related factors, illness variables. According to the available data, patients doctor-shop for a number of personal reasons, as well. Importantly, these reasons may relate to illness characteristics rather than psychological dysfunction. For example, doctor shopping may be due to symptom persistence,[1] a lack of understanding of either the proffered diagnosis or the treatment,[2] and/or no improvement in the illness.[11] In addition, patients may seek other providers because of the chronicity of the illness or disbelief in either the diagnosis or treatment.[10] According to Macpherson et al,[3] there appear to be several specific medical diagnoses that are associated with consultations with multiple providers: upper respiratory tract infection, urinary tract infection, and gastroenteritis.[3] On a side note, Leung et al[15] determined that doctor shopping was associated with failed appointments.

Patient-related factors, psychological dysfunction. A number of investigators have attributed doctor shopping to psychological dysfunction. At a broad clinical level, Norton et al16 examined data from 1,079 French patients visiting general practitioners and reported that, according to the physicians, doctor shopping was associated with higher rates of mental illness. Woollcoot et al[17] described their experience with the parents of pediatric patients who had seen multiple providers and asserted a “serious emotional problem within the family.” Fink[18] studied 282 Danish patients with somatization and reported higher rates of multiple physician visits (described by the author as doctor shopping), thereby associating somatic preoccupation with healthcare over-utilization. Finally, de Zwaan and Muller[19] reported that medically unexplained symptoms are a factor that contributes to doctor shopping. These preceding data suggest associations between doctor shopping and nonspecific emotional dysfunction as well as multiple somatic symptoms.

The patent majority of commentaries and empirical studies examining patient factors related to doctor shopping reside in the area of substance misuse/abuse. In this regard, Lineberry and Bostwick[6] indicated that doctor shopping is a traditional method for acquiring drugs illicitly. Klienschmidt et al20 reported that many patients in treatment in a drug and alcohol program disclosed that doctor shopping for benzodiazepines was easily accomplished. Pradel[21] identified doctor shopping as a concern with French patients in buprenorphine maintenance treatment.

As for empirical studies on doctor shopping and the seeking of illicit drugs, in a Norwegian study, Winther and Bramness[22] found relationships between the number of physicians consulted and the prescription of addictive drugs. In this investigation, the two study cohorts consisted of patients consulting with five or more physicians for either 1) addictive drugs or 2) nonaddictive drugs. The percentage of patients in the addictive-drug cohort was 9.5 times higher than the percentage of patients in the nonaddictive cohort. In a patient sample from Hong Kong, Dong et al[23] found empirical associations between doctor shopping and benzodiazepine abuse. In examining the prescription drugs most associated with doctor shopping, Wilsey et al[24] reported that opioids were most common (12.8%), followed by benzodiazepines (4.2%), stimulants (1.4%), and weight-loss medications (0.9%).

Importantly, not all studies have found relationships between doctor shopping and prescription misuse. For example, in a different study by Wilsey et al,[25] using data from the California Prescription Monitoring Program, investigators did not find a relationship between doctor shopping and the abuse of opioids.

With regard to the intersection of doctor shopping and prescription abuse, two related studies are of interest. First, Hall et al[7] examined unintentional pharmaceutical-overdose fatalities. In this unusual cohort, 21.4 percent of the decedents demonstrated evidence of doctor shopping before death. Second, available data indicate that the use of prescription monitoring programs decreases the prevalence of doctor shopping.[26] States with current prescription drug monitoring programs are displayed in Table 1.[27]

Sansone_Tab1

Conclusions

Doctor shopping is a relatively complex phenomenon. While all forms of doctor shopping entail multiple visits with a clinician, the patient rationales for these excessive utilization patterns may vary from physician-related factors to patient-related factors. On the one hand, doctor shopping may simply be related to office factors, clinician characteristics, communication concerns, and/or patient illness characteristics. On a more ominous note, doctor shopping may be in the service of obtaining unnecessary prescription medications for illicit use. The salient point here is that doctor shopping represents a broad range of patient behaviors that extend beyond merely procuring illicit prescription medications.

References

1. Lo AY, Hedley AJ, Pei GK, et al. Doctor-shopping in Hong Kong: implications for quality of care. Int J Qual Health Care. 1994;6:371–381.

2. Hagihara A, Tarumi K, Odamaki M, Nobutomo K. A signal detection approach to patient-doctor communication and doctor-shopping behaviour among Japanese patients. J Eval Clin Pract. 2005;11:556–567.

3. Macpherson AK, Kramer MS, Ducharme FM, Yang H, Belanger FP. Doctor shopping before and after a visit to a paediatric emergency department. Paediatr Child Health. 2001;6:341–346.

4. Pradel V, Delga C, Rouby F, Micallef J, Lapeyre-Mestre M. Assessment of abuse potential of benzodiazepines from a prescription database using “doctor shopping” as an indicator. CNS Drugs. 2010;24:611–620.

5. Rouby F, Pradel V, Frauger E, et al. Assessment of abuse of tianeptine from a reimbursement database using “doctor shopping” as an indicator. Fundam Clin Pharmacol. 2011;26:286–294

6. Lineberry TW, Bostwick JM. Taking the physician out of “physician shopping”: a case series of clinical problems associated with internet purchases of medication. Mayo Clin Proc. 2004;79:1031–1034.

7. Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613–2620.

8. Shaffer EG, Moss AH. Physicians’ perceptions of doctor shopping in West Virginia. W V Med J. 2010;106:10–14.

9. Wang MJ, Lin SP. Study on doctor shopping behavior: insight from patients with upper respiratory tract infection in Taiwan. Health Policy. 2010;94:61–67.

10. Sato T, Takeichi M, Shirahama M, Fukui T, Gude JK. Doctor-shopping patients and users of alternative medicine among Japanese primary care patients. Gen Hosp Psychiatry. 1995;17:115–125.

11. Hassan N, Ismail SB, Noor SH. Doctor-shopping behaviour amongst adult patients attending family medicine clinic, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan. Int Med J. 2005;12:251–257.

12. Yeung RY, Leung GM, McGhee SM, Johnston JM. Waiting time and doctor shopping in a mixed medical economy. Health Econ. 2004;13:1137–1144.

13. Feroni I, Peretti-Watel P, Paraponaris A, et al. French general practitioners’ attitudes and prescription patterns toward buprenorphine maintenance treatment: does doctor shopping reflect buprenorphine misuse? J Addict Dis. 2005;24:7–22.

14. Kasteler J, Kane RL, Olsen DM, Thetford C. Issues underlying prevalence of “doctor-shopping” behavior. J Health Soc Behav. 1976;17:329–339.

15. Leung GM, Castan-Cameo S, McGhree SM, Wong IO, Johnston JM. Waiting time, doctor shopping, and nonattendance at specialist outpatient clinics: case-control study of 6495 individuals living in Hong Kong. Med Care. 2003;41:1293–1300.

16. Norton J, de Roquefeuil G, David M, et al. The mental health of doctor-shoppers: experience from a patient-led fee-for-service primary care setting. J Affect Disord. 2011;131:428–432.

17. Woollcott P Jr, Aceto T Jr, Rutt C, Bloom M, Glick R. Doctor shopping with the child as proxy patient: a variant of child abuse. J Pediatr. 1982;101:297–301.

18. Fink P. Admission patterns of persistent somatization patients. Gen Hosp Psychiatry. 1993;15:211–218.

19. de Zwaan M, Muller A. Doctor shopping: the difficult-to-manage patient. Wien Med Wochenschr. 2006;156:431–434.

20. Klienschmidt R, Price J, Caught K. Doctor shopping. Aust Fam Physician. 1995;24:1037–1041.

21. Pradel V, Thirion X, Ronfle E, et al. Assessment of doctor-shopping for high dosage buprenorphine maintenance treatment in a French region: development of a new method for prescription database. Pharmacoepidemiol Drug Saf. 2004;13:473–481.

22. Winther RB, Bramness JG. Prescription shopping of addictive drugs in Norway. Tidsskr Nor Laegeforen. 2009;129:517–520.

23. Dong Y, Winslow M, Chan YH, Subramaniam M, Whelan G. Benzodiazepine dependence in Singapore. Subst Use Misuse. 2007;42:1345–1352.

24. Wilsey BL, Fishman SM, Gilson AM, et al. Profiling multiple provider prescribing of opioids, benzodiazepines, stimulants, and anorectics. Drug Alcohol Depend. 2010;112:99–106.

25. Wilsey BL, Fishman SM, Gilson AM, et al. An analysis of the number of multiple prescribers for opioids utilizing data from the California Prescription Monitoring Program. Pharmacoepidemiol Drug Saf. 2011;20:1262–1268.

26. Pradel V, Frauger E, Thirion X, et al. Impact of a prescription monitoring program on doctor-shopping for high dosage buprenorphine. Pharmacoepidemiol Drug Saf. 2009;18:36–43.

27. US Department of Justice, Drug Enforcement Administration, Office of Diversion Control. State Prescription Drug Monitoring Programs. Located at: http://www.deadiversion.usdoj.gov/faq/rx_monitor.htm. Accessed on January 13, 2012.

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Category: Mental Disorders, Past Articles, Primary Care, Psychiatry, Psychology, The Interface

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