Proving the Sky Blue

Ezekiel Emanuel's group has a paper in JAMA Oncology this month that seeks to assess the role "demanding patients"  have on overall health care costs in oncology.  They conclude as follows:

 Patient demands occur in 8.7% of patient-clinician encounters in the outpatient oncology setting. Clinicians deem most demands or requests as clinically appropriate. Clinically inappropriate demands occur in 1% of encounters, and clinicians comply with very few. At least in oncology, “demanding patients” seem infrequent and may not account for a significant proportion of costs.

Well that's all good and well.  I don't necessarily agree with the conflation of "demand" with "request"--- to wit, a cancer patient asking for an adjustment in dosage of pain medications ought not to be equated with a patient who insists upon an MRI for low back pain.   But whatever.  I don't disagree with the results.  In my own clinical practice I cannot remember an incident where I was forced to order some expensive test because an overly Google-ized patient demanded it.  

My problem with this paper is the underlying premise.  The opening sentence of the abstract is:

Surveyed physicians tend to place responsibility for high medical costs more on “demanding patients” than themselves. 

Who, I wonder, are these "surveyed physicians"?  Is there a citation in the bibliography to support such a claim? Of course not.  Who exactly are all these physicians who are blaming patients for the healthcare cost spiral?  Why is it taken as indisputable, unassailable knowledge that doctors attribute health care costs to patient demands?  And yet, this "fact" serves as the premise of the entire project.  And the Emanuel group dutifully goes about proving that, no, patient demands do not significantly impact either physician decision making or the number of tests ordered.  They have demonstrated the invalidity of a claim that no one is making anyway.  At least not by doctors.  I guess that counts as research these days.  

The reality is that this is propaganda.  Physicians are greedy.  They will do anything to preserve fee-for-service models.  They blame others for healthcare costs.  They blame patients for the tests they order.  See?  This study has proven it.....