If you build it, they will come — and how. The "it" in this case is a medical infrastructure offering patients abundant health care. Just as highway engineers have found that building bigger and better roads can paradoxically increase traffic congestion, a new study suggests that physicians working in areas where there is an extensive medical infrastructure are less happy with the quality of the care they provide than doctors working elsewhere.

That's one of the findings in a study titled "Regional Variations in Health Care Intensity and Physician Perceptions of Quality of Care," published in the May 2 edition of the Annals of Internal Medicine.

"Although the highest-intensity regions have substantially more hospital beds and specialists per capita, physicians in these regions reported more difficulty obtaining needed services for their patients," says the study. "The proportion of physicians who felt able to obtain elective hospital admissions ranged from 50 percent in high-intensity regions to 64 percent in the lowest-intensity region...."

Furthermore, "compared with low-intensity regions, fewer physicians in high-intensity regions felt able to maintain good ongoing patient relationships...."

The findings at first appear to be counterintuitive. "One might expect that physicians in low-intensity regions, where beds and physicians are relatively scarce, would be more likely to perceive resource constraints and barriers to providing high-quality care," says the study. "Given a smaller local supply of physicians, they might have to work harder than those in high-intensity regions and feel less satisfied with their relationships with other physicians and patients, and with the quality of care they are able to provide."

Elliott Fisher, MD, of Dartmouth Medical School, the study's senior author, tells the Chicago Tribune that doctors working where there are a lot of medical resources "to the surprise of many ... perceive the quality of care to be worse on almost every dimension that we looked at. Doctors are less satisfied, and they perceive the resources to be scarcer, even when they have more."

The data, based on telephone surveys with 10,577 physicians, reflect a situation where "demand feeds supply, feeds demand, feeds supply in sort of a never-ending cycle," Brenda Sirovich, MD, lead author of the study, tells the newspaper.

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