Larry Hand
October 15, 2014
It will take a dramatic shift in attitudes and culture for physicians and patients to address the problem of medical overtesting and overtreatment, two physicians argue in an article published onlineOctober 14 in the BMJ.
Jerome R. Hoffman, MD, and Hernal K. Kanzaria, MD, from the Emergency Medicine Center at the University of California, Los Angeles, contend that intolerance for error among physicians and patients and the practice of defensive medicine in a culture of blame drive overtesting and overtreatment in healthcare systems such as the one in the United States.
Both the intolerance and the culture “need to be confronted if we are to tackle the problem of ‘too much medicine,’ ” they write. “[W]e must try to change both the incentives that currently reward overtesting and overtreatment and the disincentives of public shaming and potential lawsuits whenever a diagnosis is ‘missed’ or a possible treatment withheld.”
They cite published research that shows that malpractice reform will not be enough to reduce overdiagnosis and overtreatment, including onestudy finding that “physicians’ fear of malpractice may not decrease even when tort reforms make the risk of a lawsuit objectively low.”
The authors point out that some efforts are already under way as “a commendable first step” to address overtreatment, including the “do not do” list of services from the UK National Institute for Health and Clinical Excellence and the “Choosing Wisely” campaign of the American Board of Internal Medicine. They suggest these efforts could be integrated into physician performance measures.
They also mention JAMA Internal Medicine‘s “Less is More” section and BMJ‘s “Too Much Medicine” campaign, as well as recent preventing overdiagnosis conferences that “will also help.”
Ultimately, however, the culture of medicine and the wider culture will have to change, they contend. “This will require us to be more open about the inevitability of failure, and even of error, and encouraging both the profession and the public to acknowledge and start to define an ‘acceptable miss’ rate.”
Novel Presentation
“The article lays out the issues in a novel way,” Helen Burstin, MD, MPH, chief scientific officer at the National Quality Forum in Washington, DC, toldMedscape Medical News. “I thought, in particular, their emphasis on the efforts in the US and internationally to come up with the lists of services that should not routinely be done…was a really important piece of it. Their point about how further to integrate these efforts into performance measures is really important.”
In addition, having knowledgeable patients sharing in decision making “is really going to be a game changer,” Dr Burstin added. “I think the experience, for example, of the marketplaces where people have to go and pick their insurance and really learn and read about what those options are [will be beneficial]. Over time, we’ll see more engaged patients.”
The authors and Dr Burstin have disclosed no relevant financial relationships.
BMJ. Published online October 14, 2014. Full text