Unnecessary Overuse of Medical Care Causes Waste and Harm
Unnecessary Overuse of Medical Care Causes Waste and Harm
What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:
The authors contend that each factor reinforces and amplifies the others, resulting in a "perfect storm of 'more.'"
A major driver, several doctors agree, is a culture that has long embraced the "more is better" mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: "More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I'm getting more, if I'm spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better." A collective "cultural blind spot," he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.
At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.
"Diagnostic uncertainty really feeds into a system where we have ready access to lots of things," Dr. Combs says. "We have such a supply of tests, whether that's blood tests, whether that's imaging tests, whether that's access to consultations with subspecialists— we have a system that can supply whatever demand we seem to have."
Dr. Shah calls it a "hidden curriculum" that imposes its will on doctors' discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.
"When you're criticized by your colleagues or by your mentors, it's always for things that you didn't do but could've done, and it's never about the things that you did do but didn't have to," he says.
Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20 century.
"You learn to do things the way they've always been done," he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. "That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study," he says.
High-value care is now emerging as a third outgrowth along the medical training pathway. "It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less," Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that's constantly in flux.
"Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more," says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. "Because there's so much that we don't know, sometimes we like to ask more questions by ordering more tests to try and find the answer," Dr. Fogerty says. "So it's almost an endless quest for knowledge, an endless hope that the answer's under some rock if we just turn over enough rocks."
As reform advocates are finding, however, even ample evidence isn't always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
"I feel very strongly, actually, that for physicians to improve the value of care we're delivering, it doesn't require a new set of knowledge," he says. "It doesn't require training in health policy or health economics; it's stuff that we already know."
It may require intervention before practice patterns become deeply engrained, however. According to Medscape's Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, "No, because these guidelines are not in the patient's best interest," while 24% said, "No, because I am still going to practice defensive medicine."
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. "We don't have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order— how those tests can influence our clinical management," she says.
Dr. Accurso agrees. "My recollection of my training, which would have only been seven years ago, is that there wasn't much discussion of when not to order," he says.
Although defensive medicine and the fee-for-service payment structure clearly aren't helping anti-waste efforts, Dr. Shah says they're often used as excuses to mask other issues. Residents in an academic medical center, for example, don't make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it's often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient's hospital stay.
(Enlarge Image)
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
"Instead of requesting outside films and outside studies, it's easier to repeat it," says Dr. Arora, who serves as director of educational initiatives for Costs of Care. "That just speaks to the fact that we don't have good electronic systems that actually allow for those care transitions to take place."
In a joint editorial entitled, "First, Do No (Financial) Harm," Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable— consequences for patients.
A Culture of "More"
What contributes to so much unnecessary overuse? Drs. Emanuel and Fuchs cite multiple factors:
Physician training and culture;
The fee-for-service payment structure;
Aggressive marketing by developers of tests, drugs, and procedures;
Defensive medicine;
A cultural preference for technological solutions; and
A lack of transparency on the true costs of care.
The authors contend that each factor reinforces and amplifies the others, resulting in a "perfect storm of 'more.'"
A major driver, several doctors agree, is a culture that has long embraced the "more is better" mantra. Brandon Combs, MD, assistant professor of medicine at the University of Colorado School of Medicine in Denver, puts it this way: "More information is better. More interventions are better. More scans are better. More surgery is better. More pills are better—this concept that if I'm getting more, if I'm spending more, if it costs more, then it must be kind of like a Mercedes. It must actually be better." A collective "cultural blind spot," he adds, leaves both doctors and patients unable to focus on anything beyond the upsides of care.
At the same time, medicine has reinforced the notion among trainees and attending physicians alike that doctors can never be wrong or miss a diagnosis.
"Diagnostic uncertainty really feeds into a system where we have ready access to lots of things," Dr. Combs says. "We have such a supply of tests, whether that's blood tests, whether that's imaging tests, whether that's access to consultations with subspecialists— we have a system that can supply whatever demand we seem to have."
Dr. Shah calls it a "hidden curriculum" that imposes its will on doctors' discretion. Case studies, for example, routinely focus on doctors ordering multiple tests in search of exceedingly rare causes of disease instead of being good stewards of limited resources.
"When you're criticized by your colleagues or by your mentors, it's always for things that you didn't do but could've done, and it's never about the things that you did do but didn't have to," he says.
Anthony Accurso, MD, instructor of medicine at the Johns Hopkins Bayview Medical Center in Baltimore, says the current system grew out of an apprenticeship model of medical training that dominated for much of the 20 century.
"You learn to do things the way they've always been done," he says. About 20 years ago, however, healthcare providers began shifting toward evidence-based medicine. "That was a retreat from doing things the way they had always been done and a movement toward doing things that proved themselves to be effective though evidence and study," he says.
High-value care is now emerging as a third outgrowth along the medical training pathway. "It says if there are two evidence-based treatments, both of which are effective but which have different costs, then it is rational and in fact prudent to do the one that costs less," Dr. Accurso says.
The existing evidence base is far from complete, however, meaning that some decisions must be made without clear guidelines. And beyond the remaining uncertainties, doctors often struggle to keep up with evidence that's constantly in flux.
"Things that are doctrine right now might be considered blasphemous in 10 or 15 years as we learn more," says Robert Fogerty, MD, MPH, an academic hospitalist and assistant professor of medicine at Yale University School of Medicine in New Haven, Conn.
Those realities work against the natural desire to be right and safe, which can lead to redundant tests, extra therapeutics, and additional monitoring. "Because there's so much that we don't know, sometimes we like to ask more questions by ordering more tests to try and find the answer," Dr. Fogerty says. "So it's almost an endless quest for knowledge, an endless hope that the answer's under some rock if we just turn over enough rocks."
As reform advocates are finding, however, even ample evidence isn't always enough. Dr. Shah points out that healthcare providers have known about the importance of hand washing, for example, for well over a century. And yet the field is still battling noncompliance.
"I feel very strongly, actually, that for physicians to improve the value of care we're delivering, it doesn't require a new set of knowledge," he says. "It doesn't require training in health policy or health economics; it's stuff that we already know."
It may require intervention before practice patterns become deeply engrained, however. According to Medscape's Physician Compensation Report for 2012, two-thirds of the more than 24,000 respondents rejected the idea of cutting back on testing to contain costs. Roughly 43% responded, "No, because these guidelines are not in the patient's best interest," while 24% said, "No, because I am still going to practice defensive medicine."
Medical students and residents receive great training on how to diagnose and treat diseases, says Stephanie Chen, MD, an internal medicine resident at Johns Hopkins Bayview Medical Center in Baltimore. "We don't have good training on how to interpret tests and understand the sensitivity and specificity of the tests that we order— how those tests can influence our clinical management," she says.
Dr. Accurso agrees. "My recollection of my training, which would have only been seven years ago, is that there wasn't much discussion of when not to order," he says.
Although defensive medicine and the fee-for-service payment structure clearly aren't helping anti-waste efforts, Dr. Shah says they're often used as excuses to mask other issues. Residents in an academic medical center, for example, don't make any more money from over-ordering and are relatively protected from medical malpractice. And yet, he says, overutilization is rampant there too. Why?
After talking to residents around the country, he and his Costs of Care team tallied 10 contributing factors, most of which the group believes can be addressed more easily than either tort reform or payment reform. Among the factors, the group found that residents often use preemptive or prophylactic ordering to save time or minimize future workloads. In a busy ED, it's often easier and faster to order five tests at once than to order each one sequentially after careful thought.
Vineet Arora, MD, MAPP, FHM, a hospitalist at the University of Chicago, has seen the prophylactic testing phenomenon at work when providers order an EKG or MRI ahead of time to hold their spot in line, just in case they might need the test before discharging a patient. That strategy can backfire, however, if everyone uses the same tactic and needlessly delays access for patients who really need it, or if the extra testing yields incidentalomas that require additional workup and extend the patient's hospital stay.
(Enlarge Image)
Hospitals also contribute to the problem through duplicate ordering or repeating tests performed elsewhere.
"Instead of requesting outside films and outside studies, it's easier to repeat it," says Dr. Arora, who serves as director of educational initiatives for Costs of Care. "That just speaks to the fact that we don't have good electronic systems that actually allow for those care transitions to take place."
In a joint editorial entitled, "First, Do No (Financial) Harm," Drs. Arora, Shah, and Moriates drive home the point that these lapses have very real—and avoidable— consequences for patients.
