Not too long ago one of my contact, a cardiologist wrote to his Congress person about the cuts for cardiology and received no a response after having met in person at a dinner, so we have distracted and disruptive people making laws too. Anyway, back to the point here below is a couple paragraphs from his letter and he spells out pressure as it affects him pretty clear, no question here. 
He talks about being interrupted all the time, seeing patients in the office, at the hospital and doing stent and other surgeries, and is pretty much available on call 24/7. I thinks is stress. Also mentioned if the fact that so many eyes are watching every move and any one mistake is evaluated to the highest level today, whether it needs to be or not. As he mentions “hovering over us” and that may not be the literal translation but their are “the consultants” at most hospitals and utilization managers that are there to control cost and sometimes could remind you of a Monday morning quarterback at times, but these are the folks that track and analyze all the procedures, complaints, treatments, etc.
These folks pay for mal practice insurance too and as mentioned here, a somewhat new element, hospital marketing. I agree with the content of this article as the hospitals can add more pressure as they are all running some concise business intelligence software so they can operate efficiently. BD
Pressure = Algorithms for performance
“We are interrupted at every sacred moment of our lives.
We go thru hell trying to balance seeing patients in the office during the day, running to several hospitals to see patients during the day and night, squeeze in performing surgeries (stents, pacemakers, etc) and be available at any time every day and night. The demands are incredible and perhaps more so than any other medical specialty................and all this now for free!
We live in constant fear that a simple error in judgment (whether it be because of lack of sleep or dealing with the stresses of simultaneous emergencies, etc) or a miscommunication will result in serious consequences for patients let alone to us and our families. We are aware there are attorneys and medical boards, confidentiality organizations, etc hovering over us to catch us off guard. We don't need these additional stressors. We are nowadays seeing more and more patients in the hospital who have no insurance and we are taking care of them for free (pro bono).
Unfortunately, healthcare isn't that simple. A physician may be worried about a crippling lawsuit if he or she misses a diagnosis. Or the patient may be convinced that a particular drug will do the trick and is asking for it by name. Maybe the hospital has been marketing a new piece of equipment and hinting at referrals. And who even knows if the patient's insurance will reimburse for every treatment option?”
Physician decision-making has been a central focus of the reform discussions about rising healthcare costs. While most doctors make clinically-sound decisions for nearly all patients, there are external pressures that can influence and increase the tests and procedures doctors order at the margins. An occasional unnecessary test times thousands of physicians and millions of patient encounters can quickly equal billions in unnecessary healthcare spending.
But J. James Rohack, MD, president of the American Medical Association, says the survey results may also reflect the complexity of the reimbursement system and the hoops physicians have to jump through to ensure that they will be reimbursed for their work. "If I'm going to provide a service and I'm not going to get paid for it then I have to communicate that with the patient ahead of time, because otherwise, that may be a non-covered benefit and I'm going to have to deal with it," he says
The Pressures on Physician Decision-Making
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