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Doctor Knows Best: The Influence of Physician Leadership on Public Opinion

In American democracy, public recognition of societal problems often requires prompting from elites. To be sure, voters do not need to be told that traffic congestion in their neighborhoods is getting worse, the major local employer has gone bankrupt, or gas prices are rising. They can see tangible evidence of such problems with their own eyes. But the more complex, subtle, or remote from daily experience problems are, the less likely voters are to discern them on their own. A key question for the performance of U.S. political and economic institutions is whether the policy elites who are in a position to educate the public about the existence of important but less readily apparent problems will do so, or, alternatively, whether they will permit citizens to remain uninformed.

When it comes to public understanding of the “medical guesswork” problem and the large costs it imposes on both patients and the nation, no set of opinion leaders is more important than doctors. In this chapter, we draw on the results of five national surveys we carried out between 2009 and 2011 to explore how public confidence in doctors and the medical profession affects public support for proposals to improve the evidence base.¹ The surveys had sample sizes between 1,100 and 3,600,²and they were representative of the general U.S. population on a variety of characteristics, including gender, income, race, and health insurance status.³

The surveys demonstrate that doctors possess the influence, prestige, and standing to play a leadership role in educating the public about the inefficiencies and waste of the U.S. health care system. The public views doctors as more honest and hardworking than other professional groups. Americans believe that doctors are experts who are empathetic and concerned about helping people, and do not see economic incentives as a primary driver of doctors’ behavior. Because most Americans believe “doctor knows best,” they tend to have confidence in the advice of doctors, not only about individual medical problems, but also about broader health care reform issues. As Mark A. Peterson has persuasively argued, the trust that patients have in their doctors as medical healers leads to a broad-based social trust in doctors as policy experts and faithful representatives of the public’s welfare in policy debates.⁴

Our surveys also reveal that Americans are naturally wary of health care reform proposals they fear could constrain physician discretion, such as requiring doctors to follow evidence-based clinical guidelines. The public’s anxieties about proposals to make medicine more evidence based, however, can be overcome. Using survey experiments, we demonstrate that physician endorsements of such reforms significantly alleviate public fears. Our survey results suggest that if doctors were to become forceful advocates for reform, their reputations as trusted, well-motivated experts position them to shape the views of ordinary citizens. In sum, we argue not only that doctors have the professional responsibility to exercise public leadership on improvements to the health care system, but also that they have an opportunity to do so.

An Agency Model of Doctors’ Persuasive Influence

The tendency of the public to defer to doctors for guidance both on personal medical problems and broader health reform issues⁵ can be understood if the relationship between doctors and patients is considered from the perspective of principal-agent theory. “Agency” relationships are ubiquitous in a complex modern economy. They arise whenever a “principal” enters into a contract or agreement with an agent in which authority is delegated to the agent to perform a task on the principal’s behalf or to make decisions that affect the principal’s well-being.⁶ For example, people hire financial advisers to recommend stocks, lawyers to draw up wills, and doctors to cure their ills; such delegation makes people better off. However, problems can occur in an agency relationship when, as is often the case, the agent has more information than the principal. An agent could take advantage of the principal’s trust by engaging in behavior that is costly for the principal to detect. For example, a car mechanic could recommend a costly repair to fix a part that is not really broken. When such information asymmetries arise, the challenge is to align the interests of the agent with those of the principal. A variety of mechanisms can be used to mitigate this problem, from contractual safeguards and warranties to government oversight and the creation of social norms against opportunistic behavior and self-dealing. The ethical norm of medical professionalism, licensure, and self-regulation can all be seen as responses to the agency problem in medicine.⁷ How well these mechanisms are currently working in the U.S. health care system, however, is debatable. Indeed, the evidence we present in this book suggests that these arrangements often fail to protect patients’ interest in receiving appropriate treatments for their conditions grounded in the best possible scientific evidence. From the standpoint of understanding the sources of doctors’ persuasive influence on ordinary citizens, however, the crucial consideration is how the public perceives its agency relationship with physicians, not whether the relationship is actually working optimally.

The foundation of persuasive communication in a principal-agent framework is that the agent (the doctor) possesses expertise and either naturally shares the interests of the imperfectly informed principal (the patient) or has adequate incentives to act in the principal’s interest.⁸ Beyond seeing doctors as charismatic figures who offer emotional support, patients, who are typically ill-informed about both medicine and health care policy, may regard doctors as trustworthy experts who are motivated to protect their well-being. If so, this would promote the public’s willingness to accept cues regarding the desirability of health policies from doctors and medical associations. Our survey results suggest that these two conditions are easily satisfied. The American public generally believes that doctors are (1) technically proficient and (2) their allies.⁹ That is, the public believes doctors not only know best, but are also strongly motivated to do the right thing for patients.

Public Beliefs about the Motivations of Doctors and Medical Societies

That the public has bedrock trust in doctors is an easily overlooked feature of the U.S. health care system. Many studies have documented a decline in the public’s confidence in the medical profession and its leaders over time.¹⁰ For example, 73 percent of Americans “said they had a ‘great deal of confidence in the people in charge of running medicine’ in 1966. In 2010 only 34 percent expressed that level of confidence.”¹¹ The decline in confidence in medicine may reflect not only a general decline in public confidence in government and other major institutions over the past several decades,¹² but also broad changes in the political economy of health care. In the 1960s, patients had relatively few treatment options, the health sector made up a small share of the economy, and organized medicine possessed an issue monopoly over health policy. Today, concerns about rising medical costs, increasing premiums and deductibles, and government budget deficits have sparked debates about the value of dollars spent and created a more open and contentious health politics.¹³

But these important developments should be kept in perspective. Although the medical profession may not enjoy the same absolute level of confidence as it once did, what also matters from a political standpoint is the status and influence of doctors relative to other actors in the health care arena such as elected officials, drug companies, and health insurance companies. Many Americans recognize that the health care system does not always serve the interests of patients, but most blame actors other than doctors for the system’s flaws. Despite the secular decline in confidence in the medical profession, Americans view doctors as being honest and generally trust doctors to recommend the right thing for the country on health care.¹⁴ In a 2008 Gallup survey, 64 percent of Americans believed doctors had very high or high ethical standards, up from 56 percent in 1976.¹⁵ In contrast, on a separate nationally representative survey that we conducted, 68 percent of the public agreed that “drug companies keep cures for some serious medical conditions secret from the public to protect the profits they get from their current products.” Despite the erosion of medical authority in American politics since the 1960s,¹⁶ the public continues to display remarkable faith in physicians compared to other groups.¹⁷

In one survey, we randomly assigned respondents to evaluate one of four professions: doctors, lawyers, grade school teachers, or members of Congress. We asked respondents to rate their agreement with a series of six statements about the motivations of individuals from their randomly assigned profession. For example, those in the “doctors” condition were asked how much they agreed with the statement: “Doctors are interested in helping people.” We measured responses on a five-point scale ranging from “strongly disagree” (1) to “strongly agree” (5).

FIGURE 3.1. Beliefs about the motivations of doctors compared to other professions. Note: Mean responses to the question: “How much do you agree with each of the following statements?” Responses were measured on a five-point scale ranging from “strongly disagree” (1) to “strongly agree” (5). N represents the number of respondents randomly assigned to evaluate each profession. All the differences in the public’s assessment of doctors compared to other professions are statistically significant at p<.05, two-tailed, with the exception of the differences between doctors and school teachers on the “interested in helping people” (p=.26) and “can be trusted” (p=.25) items. Source: February 17–23, 2011, YouGov/Polimetrix survey. A version of this figure was originally published as figure 1 in Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling, 2014, “Doctor Knows Best: Physician Endorsements, Public Opinion, and the Politics of Comparative Effectiveness Research,” Journal of Health Politics, Policy and Law 39 (1): 171–208. Copyright 2014, Duke University Press. All rights reserved. Republished by permission of the publisher. www.dukeupress.edu.

Figure 3.1 displays mean responses to these six items for each profession. The results indicate that respondents view doctors as harder workers, more interested in helping people, more trustworthy, and as caring more (“about people like me”) than each of the other professions.¹⁸ To be sure, the public does not view doctors as exclusively altruistic,¹⁹ but it does view doctors as being less driven by a desire to gain greater wealth and prestige than members of other elite professions, such as lawyers and members of Congress.

Although people interact most directly with their personal doctors, medical societies have a substantial influence on public policy. They take positions on proposed changes to federal rules and make recommendations for coverage and reimbursement decisions under Medicare that affect program beneficiaries and taxpayers.²⁰ When studies are published about the effectiveness of a common treatment—as in the knee arthroscopy case discussed in chapter 2—medical societies may issue statements about the research methodologies used and the significance of the study findings.²¹ Our national physician survey (discussed in chapter 4) shows that most doctors want their medical societies to take an active role in critiquing studies that challenge the benefits of treatments in their practice areas. The statements of medical societies about the effectiveness of treatments are often quoted in the media and may in turn shape public beliefs about not only the perceived benefits of particular medical services, but also about the overall quality and efficiency of the U.S. medical system. In adopting positions that mold public opinion and influence public policy, at least, medical associations exist in large part to advance the economic interests of their members and are similar to other organizations, such as unions, trade associations or industry groups. But does the public believe doctor associations share the same motivations as other economic organizations?

To find out, we asked respondents to evaluate the importance of several factors in explaining why various groups make policy recommendations. We randomly assigned each respondent to evaluate the motivations of one of four groups: medical associations, unions, business organizations, or health insurance organizations. We investigated the importance of the following five motivations: (1) maintaining high income for group members; (2) preserving the group’s influence over policy makers; (3) promoting the health of patients (for medical associations and health insurance organizations) or workers (for business organizations and unions); (4) ensuring that new laws and regulations help their industry; and (5) protecting doctors from malpractice suits (for medical associations and health insurance organizations only). We measured responses on a five-point scale ranging from “not at all important” (1) to “extremely important” (5).

Figure 3.2 displays the percentage of respondents that chose either of the top two response categories: “very important” or “extremely important.” The results show that the public sees the desire to maintain high incomes for group members and to preserve group influence over policy makers as being weaker motivations for medical associations than for unions and business organizations. Only 45 percent of respondents stated that “maintaining high incomes” was either very or extremely important to medical associations, whereas 60 percent and 55 percent said the same for unions and business organizations. The public also perceives medical associations as being more concerned about promoting patient health (65 percent selected very or extremely important) than health insurance organizations (56 percent), and more concerned about promoting patient health than unions (54 percent) and business organizations (43 percent) are concerned about promoting worker health. The public does, however, see the desire to protect doctors from malpractice suits as being a stronger motivator for medical associations (61 percent) than for health insurance organizations (49 percent).

FIGURE 3.2. Beliefs about the motivations of medical associations compared to other groups. Note: Responses to the question: “When developing their recommendations, how important do you think each of the following considerations is to these groups?” Number of observations for each randomly assigned group were 348 (medical associations), 352 (unions), 370 (business organizations), and 342 (health insurance organizations). Responses were measured on a five-point scale ranging from “not at all important” to “extremely important.” The figure displays the percent who responded that the consideration was “very important” and “extremely important” (the top two response categories). Source: February 17–23, 2011, YouGov/Polimetrix survey. A version of this figure was originally published as figure 2 in Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling, 2014, “Doctor Knows Best: Physician Endorsements, Public Opinion, and the Politics of Comparative Effectiveness Research,” Journal of Health Politics, Policy and Law 39 (1): 171–208. Copyright 2014, Duke University Press. All rights reserved. Republished by permission of the publisher. www.dukeupress.edu.

The Public Fears Interference with Physician Discretion

One problem that can arise in an agency relationship is that the agent may lack the expertise needed to serve the principal’s interests. As medicine becomes more complex, it becomes increasingly difficult for even diligent doctors to keep up with the latest scientific evidence about what works best for different conditions. As Austin Frakt observes,

In 2014 alone, more than 750,000 additional medical studies were published. Granted, a physician might need to keep up only with the evidence in her specialty, but even at a fraction of this rate, it is unrealistic to expect even the best physicians to assimilate every new development in their fields. In cancer alone, 150,000 studies are published annually.²²

Research suggests that, in certain areas of medicine, physicians whose practice styles deviate significantly from the statewide norm established in teaching hospitals for that year have much worse patient outcomes.²³ But while many experts argue that doctors should be required to follow evidence- based guidelines when caring for patients in order to improve care, reduce medical errors, and curb wasteful spending, respondents are skeptical of proposals that might narrow the ability of doctors to exercise their professional discretion to choose the treatments they receive.²⁴ One reason why people may be uneasy with guidelines is the belief that treatments help some people but not others and that one’s personal doctor knows if a given treatment will work for them. A majority (52 percent) of respondents agreed with the statement, “If a treatment only helps some patients who get it, your doctor knows whether you will be among those for whom the treatment is effective.”

Our surveys show that advocates who hope to build public support for evidence-based guidelines will need to overcome a variety of public concerns. We asked respondents how convincing they thought four arguments for and five arguments against evidence-based guidelines were, randomizing whether respondents read the block of “pro” or “con” arguments first as well as the order of arguments within each block.²⁵ Figure 3.3 shows that most respondents found each of the “pro” and “con” arguments to be convincing, but overall they were more likely to rate the “con” arguments as either somewhat or very convincing. They were also more likely to find the “con” arguments to be very convincing, relative to the “pro” arguments. No fewer than 55 percent of respondents were somewhat or very convinced by each of the four arguments in favor of treatment guidelines: economic incentives may cause doctors to give patients unnecessary care (63 percent); guidelines would improve care for most patients (57 percent); doctors can become out of touch with the latest research (55 percent); doctors follow local standards of care and may be unaware of better treatments being used elsewhere (55 percent). However, just 12–20 percent of respondents found these arguments in favor of guidelines to be very convincing.

FIGURE 3.3. Americans’ responses to arguments for and against treatment guidelines, 2009. Note: Responses to the question: “Here are some arguments people have given [for/against] requiring doctors to follow treatment guidelines. After each statement, please tell me how convincing the reason is.” Responses were measured on a four-point scale ranging from “not at all convincing” to “very convincing.” The figure displays the percent who responded that the argument was “very convincing” and “somewhat” plus “very convincing.” Source: November 5–December 31, 2009, YouGov/Polimetrix survey. A version of this figure was originally published by Project HOPE/Health Affairs as exhibit 1 in Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling, 2010, “A National Survey Reveals Public Skepticism about Research-Based Treatment Guidelines,” Health Affairs (Millwood) 29 (10): 1882–84. The published article is archived and available online at www.healthaffairs.org.

In general, respondents found the arguments against guidelines more persuasive. At least 70 percent of respondents were somewhat or very convinced by each of the five arguments against treatment guidelines. In fact, more than eight in ten respondents were convinced that forcing doctors to follow guidelines would prevent them from tailoring care to individual patients and that no outside group should come between doctors and patients. More than seven in ten respondents believed that guidelines are vulnerable to corruption and abuse, will be used to ration care, and will not incorporate the latest scientific breakthroughs. Moreover, the proportion of respondents finding each of these arguments to be very convincing ranged from 29 to 51 percent. The details of these results could reflect nuances in how the persuasive messages were crafted, but the substantial differences in response and the strong response to the antiguideline arguments suggests important areas of public concern.

The Public Wants Consumer Information, Not Mandates

Will the public embrace proposals to make American medicine more evidence based? Many experts believe that a significant proportion of the care that patients receive does little to improve health.²⁶ This conclusion reinforces the view that the U.S. health care system is wasteful, and that the adoption of evidence-based medicine might promote better patient outcomes and a more efficient allocation of resources. The general public, however, places tremendous faith in the curative power of modern medicine. Nearly 80 percent of respondents in our survey agreed with the statement that “the most recent medical innovations are more effective than treatments that were introduced 10 or 20 years ago,” and over 55 percent agreed that “modern medicine can cure almost any illness [with] advanced technology and treatment.” Many citizens assume that more medicine is generally better and that evidence-based guidelines limit the ability of doctors to provide appropriate care.²⁷

To be sure, a segment of the public does recognize that a great deal of medicine is not based on solid evidence. We found that 50 percent of the public agreed with the statement that half or less of the care they received is evidence based.²⁸ The public’s recognition that not all medical care is based on evidence does not, however, automatically translate into strong support for the use of research studies to mandate changes in clinical practices or the allocation of health care resources. Figure 3.4 shows that the public supports the use of CER to provide information to health care consumers, such as creating warning labels for treatments that are not supported by strong scientific evidence, but that the majority of the public does not support the use of research findings to mandate treatment decisions, determine which groups of patients should be protected from budget cuts in Medicare, or charge patients more to get a treatment that research has not shown to be effective if the patient’s own doctor recommends the treatment.

Public Fears Are Easily Stoked—but Can Be Overcome with Doctor Support

Public opinion on some issues (such as the price of gas) reflects personal experience. Other issues (such as views on abortion) reflect deeply held moral views. On such issues, ordinary people are able to form their opinions without the influence of elites. In contrast, evidence-based medicine is a highly technical issue on which public opinion is likely to be more susceptible to the influence of opinion leaders.²⁹ We performed two survey experiments to explore the relative persuasiveness of arguments made in elite discourse about the pros and cons of comparative effectiveness research in a manner that simulates the back and forth of a political debate. In each experiment, participants were presented with one argument in favor of CER and one argument opposed to it.

FIGURE 3.4. Americans’ support for uses of comparative effectiveness research, 2010. Note: Responses to the question: “To what extent would you support or oppose using comparative effectiveness research to:” Responses were measured on a five-point scale ranging from “strongly oppose” to “strongly support.” The figure displays the percent who responded that they somewhat/strongly supported and somewhat/strongly opposed; the remaining (unreported) respondents selected “neither support or oppose.” Source: May 21–24, 2010, YouGov/ Polimetrix survey. A version of this figure was originally published by Project hope/Health Affairs as exhibit 2 in Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling, 2010, “The Public Wants Information, Not Board Mandates, from Comparative Effectiveness Research,” Health Affairs (Millwood) 29 (10): 1872–81. The published article is archived and available online at www.healthaffairs.org.

In the first experiment, we assessed baseline support for government funding of CER (that is, whether respondents would support using taxpayer money to pay for medical research on the relative effectiveness of different treatments for a given medical condition), using a 0–100 sliding scale. We then randomly assigned respondents to be presented with one of two arguments in favor of CER and one of three arguments against (described below). The order of the pro and con arguments was also randomized. After reading the pair of arguments, respondents were again asked about their support for CER (using the same 0–100 sliding scale), allowing us to assess whether exposure to a stylized debate about CER moved opinion.

We used two common pro arguments. The first was that CER “will improve health care outcomes by giving patients and doctors the information they need to identify the most effective treatments.” We paired this improve outcomes argument with one of three counterarguments that CER would: (1) lead to one-size-fits-all medicine (“the government and insurance companies will use the research to tell doctors how to practice medicine. They will force doctors to follow one-size-fits-all treatment guidelines rather than being able to use their knowledge and expertise to tailor care to each individual patient”); (2) serve as an excuse to ration care (“the government and insurance companies will use the research findings as an excuse to ration care and deny coverage of effective but expensive treatments”); and (3) waste taxpayer money (“government spending on comparative effectiveness research would waste taxpayer money because doctors already know what treatments work best”).

The second pro argument was that CER “will help reduce the budget deficit by allowing the government to cut wasteful spending on ineffective treatments without lowering the quality of medical care.” We pitted this reduce deficit argument against three counterarguments: (1) one-size-fits-all, (2) ration care, and (3) that CER would reduce innovation (“cutting medical spending for any reason reduces companies’ financial incentive to develop new drugs and medical devices and that will be bad for patients in the long run”). We focus on the net effects of each of the six argument pairs on support for CER (i.e., average change in support for CER from the baseline question to the same question asked after the experiment). Table 3.1 presents a summary of the results of this experiment.

The key finding from this experiment is that exposure to the debate over CER generates concerns among the public. The net effect of seeing each of the argument pairings was to lower respondents’ support for government funding of the medical research. For example, respondents who were exposed to the improve outcomes/one-size-fits-all pairing reduced their support for CER by 10.0 points on the 100 point scale. Respondents who were exposed to the improve outcomes/ration care pairing reduced their support by 6.9 points and those exposed to the improve outcomes/waste taxpayer money pairing reduced their support by 4.2 points. When paired with the reduce deficit pro argument, the one-size-fits-all, ration care, and reduce innovation counterarguments resulted in 9.9, 8.0, and 3.0 points less support for CER, respectively.³⁰ This experiment thus underscores that the public will need to be reassured that evidence-based medicine reforms like CER won’t have negative consequences.

Note: Cell entries are weighted mean changes in support for government funding of CER by condition (with the number of observations in parentheses). The measures of support used to calculate changes each range from 0 (strongly oppose) to 100 (strongly support). For example, the –10.01 in the “Improve Outcomes” / “One-size-fits-all” cell indicates that respondents who viewed that argument pair reduced their support for government funding of CER by 10 points on the 0 to 100 scale. All weighted mean changes are significantly different from zero (p<.05).

Source: July 30–31, 2010, YouGov/Polimetrix survey.

But what arguments in support of CER would the public find most persuasive? To answer this question, we performed a second experiment in which we examined the effectiveness of rebuttals to the strongest anti-CER argument, that CER will lead to one-size-fits-all medicine. We randomly assigned respondents to receive one of four pro-CER arguments tailored to rebut the con argument: (1) CER is supported by doctors (doctors want it), (2) the one-size-fits-all argument is a scare tactic, (3) that it is important to learn what works best for most patients, and (4) that research studies can incorporate group differences and are not limited to studying average treatment effects.³¹ After they read both arguments, we asked respondents whether they found the pro or con argument to be more persuasive using a sliding scale ranging from 0 (con argument) to 100 (pro argument). Values on the response scale greater than 50 indicate that respondents found the pro-CER argument more persuasive. As table 3.2 shows, on average, people rated the tailored rebuttal as either equally or more persuasive than the argument against CER in each condition.

We found that the most effective rebuttal is that doctors want it. This rebuttal was substantially more persuasive than the one-size-fits-all argument (mean score of 65.8 on 0–100 scale). This finding points to the tremendous credibility and weight that people attach to doctors’ opinions. Only one of the other three rebuttals (can incorporate group differences; mean score of 59.9) substantially moved opinion away from the midpoint of 50.³²

The Influence of Doctors and Politicians on Public Opinion

The findings discussed above suggest that the public can be persuaded by arguments both in support of and in opposition to evidence-based medicine reforms. However, research also suggests that the identity of the actors making the arguments may prove just as important.³³ Does it make a difference if the groups endorsing or opposing the proposals are doctors, elected officials, or other political elites? We explored this question by performing two complementary survey experiments.

The design of the first experiment allows us to assess how public support for a generic proposal to “help reduce the amount we spend on health care” is affected by the support or opposition of a physicians’ group (the American Medical Association) as well as the positions of “political” groups (congressional Democrats, congressional Republicans, and a bipartisan commission on deficit reduction). We randomly assigned these support and opposition cues across respondents. The cues were designed to mimic common elements of the political debate over health care cost control.³⁴ We did not give the proposal any substantive content beyond indicating that it would help constrain health care costs because cost control is the dimension of CER that has been most controversial. We tested the influence of the position of the AMA (as opposed to the stance of other medical societies) because we believe it is the physician group best known to the general public. Further research could examine whether our findings generalize to other physician groups.

In order to determine if the AMA’s position matters, and to whom, we manipulated two dimensions of the experiment. The first dimension varied the AMA’s position. One-third of the sample was told that the AMA endorsed the proposal; another third was told that the AMA opposed the proposal; the AMA’s position on the proposal was not mentioned for the remaining one-third of the sample. The second dimension of the experiment examined the effects of political cues. Each respondent saw a statement that described the proposal as (a) “supported by congressional Democrats but opposed by congressional Republicans,” (b) “supported by congressional Republicans but opposed by congressional Democrats,” (c) “supported by congressional Democrats and Republicans” or (d) “supported by a bipartisan commission on deficit reduction.” An additional group was randomly assigned to receive no political cue. These five conditions were randomly assigned with equal probability independently of the AMA cue treatment.

In sum, we presented some respondents with the position of a single group (e.g., AMA endorsement or endorsement from a bipartisan commission) while we presented others with both a political cue and the position of the AMA. (No respondents were assigned to the condition in which neither a political cue nor the AMA cue was provided.) The outcome measure was respondents’ assessments of how the particular cue (or cues) would affect their own support for the proposal and was measured using a five-point scale ranging from “much less likely to support” (-2) to “much more likely to support” (2).³⁵

For each of the 14 experimental conditions, table 3.3 reports the average (weighted mean) for the outcome measure with standard errors in parentheses. The table also reports the average for each political cue condition, collapsing AMA conditions (in row 4), and the average for each AMA condition, collapsing political cue conditions (both including the “no political cue” cases [in column F] and not including those cases [in column G]).

Note: Cell entries are weighted means with standard errors in parentheses. Total N=1,412. Complete question wording: “A variety of public policies have been proposed to help reduce the amount we spend on health care. Suppose you learned that a proposal was [Three AMA Treatment Conditions: none / supported by the American Medical Association / opposed by the American Medical Association] [IF AMA Treatment <>none and Political Treatment <>none then “and”] [Five Political Treatment Conditions: none / supported by congressional Democrats but opposed by congressional Republicans / supported by congressional Republicans but opposed by congressional Democrats / supported by congressional Democrats and Republicans / supported by a bipartisan commission on deficit reduction]. Would this make you more or less likely to support the proposal?” Outcome measure ranges from -2 (“much less likely to support”) to +2 (“much more likely to support”).

Source: February 17–23, 2011, YouGov/Polimetrix survey. A version of this table was originally published as table 1 in Alan S. Gerber, Eric M. Patashnik, David Doherty, and Conor M. Dowling. 2014. “Doctor Knows Best: Physician Endorsements, Public Opinion, and the Politics of Comparative Effectiveness Research.” Journal of Health Politics, Policy and Law 39 (1): 171–208. Copyright 2014, Duke University Press. All rights reserved. Republished by permission of the publisher, wvw.dukeupress.edu.

Focusing on column G, we find that respondents who received the AMA support cue (row 2) were more likely to say this cue would increase their support for the proposal (mean=.30), while respondents who received the AMA opposition cue (row 3) were more likely to say it would decrease their support for the proposal (mean=-.11). This net difference between receiving AMA support or opposition cues of .41 is statistically significant (p<.001). In concrete terms, only 24 percent of the people who received the AMA opposition cue said they were (somewhat or much) more likely to support the proposal, while 38 percent of the people who received the AMA support cue said the same. Only 14 percent of those who received the AMA support cue said they were (somewhat or much) less likely to support the proposal, while 30 percent of those who received the AMA opposition cue did so.³⁶

We also expected the position of a bipartisan commission on deficit reduction to affect public opinion, but the results suggest it did not. Collapsing the AMA conditions (row 4 of table 3.3), we find that in the absence of a political cue, average support for the proposal is .12 (column A). When the bipartisan commission cue is given, average support is approximately .11 (column C).³⁷ These results imply that endorsements from bipartisan political committees are unlikely to increase public support for proposals to reduce health care spending.³⁸ Aggregate support for the proposal is also not significantly affected by the other political cues. The differences between the bipartisan commission and the other political cue conditions in row 4 are not statistically significant (p>.10 for all pairwise comparisons). Collapsing across AMA conditions (row 4), there are no statistically significant differences between any of the other political cues and the group that received no political cue or between the other political cue experimental conditions (p>.10 for all pairwise comparisons).

We expected the political cues to have different effects depending on subject partisanship, however. Although a relatively small sample limits our ability to draw reliable inferences, we do find that partisans differ substantially in their responses to directional partisan cues (see table A3.2).³⁹ Republican respondents who were presented with an endorsement cue from congressional Republicans and an opposition cue from congressional Democrats were more likely to say the information would increase their support for the proposal (mean=.95, p<.001 for difference between no political cue); among Democratic respondents, this informational condition substantially decreased support for the proposal (mean=-.57, p<.001 for difference between no political cue). Conversely, Democratic respondents who received an endorsement cue from congressional Democrats and an opposition cue from congressional Republicans were more likely to say the information would substantially increase their support for the proposal (mean=.71, p<.05 for difference between no political cue), while this combination of cues considerably decreased support among Republican respondents (mean=-.67, p<.001 for difference between no political cue).

In summary, the results from this experiment suggest that the AMA’s position may significantly influence public opinion. Although respondents who identified with a political party were strongly affected by directional cues from their party, the effects of Democratic and Republican partisan cues are largely offsetting given the aggregate distribution of partisan preferences in the overall population (see table A3.2). Only the position of the AMA influenced the attitudes of the public as a whole.⁴⁰ Neither the positions of a bipartisan commission nor a cue indicating that both parties support a proposal significantly influenced public opinion—even among Independents. These results underscore the public influence of doctors’ groups. Even without giving respondents specific reasons why a proposal would be good or bad for patients, the position of doctors has the potential to significantly increase public support or opposition.

To see whether these results persist when the proposal specifically involves an effort to use research on the comparative effectiveness of treatments as a tool to control costs, we conducted a follow-up study in which the endorsement or opposition cue explicitly referenced CER. In addition, instead of the AMA, we simply referenced “leading doctors” (and also compared their effect to those of other groups, such as patient advocacy groups and drug companies). The complete details of this follow-up experiment are described in the appendix to this chapter. The findings broadly corroborate the results of the original experiment—“leading doctors,” much like the AMA, had a significant effect on public acceptance of the CER cost-control proposal, underscoring the distinctive capacity of doctors’ groups to shape public opinion in this policy arena.

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Overall, our public opinion surveys suggest that physicians and medical associations have a distinctive capacity to influence public support reforms to control costs and improve the efficiency and evidence basis of medicine.⁴¹ No other actors in the health care system—not politicians, drug companies, or patient advocacy groups—enjoy this level of persuasive power. Our findings suggest that there is an opportunity for the medical profession to use its delegated authority to cultivate an informed public opinion and promote problem solving and social learning.