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Our health care system still massively overtreats patients, but we can change that

Our health care system still massively overtreats patients, but we can change that

Picture of Robert Pearl
[Photo by Zdenko Zivkovic via Flickr.]
More surgery doesn't always mean better care, notes Dr. Robert Pearl.

One of the biggest myths about staying healthy is that more care is better care. That commonly held belief is not only false but quite dangerous. Overtreatment can be harmful to patients, with the complications at times worse than the original problem.

While it is important to embrace innovation and new technologies that lead to breakthrough health outcomes, it is equally important to be aware of how often aggressive treatments add little value and risk harm, especially when compared to time-tested, more conservative alternatives. A 2012 article from the Medical Journal of Australia study listed over 150 interventions that have been shown to be ineffective but continue to be performed. 

Often clinical problems can be best treated through medication, watchful waiting, or physical therapy, and instead surgeons recommend an operative procedure.

A good example is arthroscopic surgery for knee pain. Multiple studies from Canada have shown that surgery on the meniscus with physical therapy compared to physical therapy alone add no value, and yet this remains the most commonly performed orthopedic procedure in the United States. Another example is radical surgery or radiation therapy for low-risk prostate cancer. Long-term studies have shown essentially no increase in life expectancy, and these interventions often lead to impotence and urinary incontinence. 

Back pain is another common condition that is overtreated. Patients undergo radiological studies that are unnecessary and fail to provide useful clinical information. Patients have surgical procedures that ultimately don’t reduce the pain any more than physical therapy alone. And increasingly complex procedures are being done without evidence that they improve long-term outcome, but do add risk.   

In contrast, there is powerful evidence that hundreds of thousands of lives could be saved every year by increased prevention, avoidance of medical error, and elimination of health care disparities by race and ethnicity. Unfortunately, the culture of medicine doesn’t value these more mundane actions as much as the newest drug or multimillion-dollar machine.

When the Dartmouth Atlas looked at rates of intervention among Medicare patients, they too concluded that not only does a higher volume of procedures not improve health care outcomes, it most likely results in poorer outcomes for patients.

Here are four reasons for the current state of overtreatment in health care:

  • A medical culture that values intervention over prevention. 
  • A fee-for-service reimbursement system that rewards the volume of care, not its value. 
  • Direct-to-consumer advertising that encourages use of the latest, most expensive drugs and invasive procedures, even when their impact on most people is minimal.
  • Physicians’ lack of time and incentives to explain why a procedure or drug is unlikely to make a difference.

As patients we worry when we hear the words cancer or heart attack. We want to believe there is a miracle cure or a doctor who is much more skilled than anyone else. When we are told about an intervention, we seek it out to reduce anxiety and fear. Psychological research has shown that our minds overvalue the potential and minimize the risks, even when the ratio is unfavorable.  And this subconscious miscalculation is as prevalent among doctors as patients.

Even at the end of our lives this tendency persists. In multiple surveys, 90 percent of people say they would prefer to die at home, but in practice two-thirds spend their last days in a hospital.

Here are four steps that could make all of us more knowledgeable and empowered.

  • Provide all patients with decision-making tools such as videos and podcasts to lower anxiety and help them better understand a procedure’s risks and benefits.
  • Shift to value-based pay practices rather than ones solely based on the volume of services to help eliminate the skewed incentives of the current fee-for-service health care payment system. 
  • Require companies to compare new procedures, devices, and drugs to currently available (often lower-cost alternatives) to determine when new approaches are better.
  • Clamp down on medical malpractice suits to lessen the amount of unnecessary care delivered happens when doctors practice defensive medicine.

Doing right by patients means consistently prescribing those interventions that have been proven to work, and recognizing how often less is more.

Dr. Robert Pearl is a reconstructive plastic surgeon and CEO of both The Permanente Medical Group and Mid-Atlantic Permanente Medical Group, and on the faculty at the Stanford University School of Business.

[Photo by Zdenko Zivkovic via Flickr.]                              


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I commend Dr. Pearl's effort to addresss this issue and suggest changes to tackle the problems identified. I wish these important aspects were also included.
1. Prevailing cultural and individual patient expectations (lack of patient/individual accountabilty).
2. Reimbursement and tort systems (steer individual practitioners and facilities towards interventional care that often lacks efficacy).
3. Lack of knowledge (patients and practitioners) and support (fragmented systems of care) for evidence-based AND cost-effective practice.
Proposed steps for improving our fragmented, triangulated care delivery system (patients, payers, and practitioners) to one that is cohesive and collaborative, is valid. Perhaps physicians need to bill as lawyers do - time taken to educate patients in or outside the office through motivational interviewing could benefit patients and practitioners.
Practice of defensive medicine is related to

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Calling it "overtreatment" is a euphemism. It's not "overtreatment," it's malpractice!

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I thank the author for sharing his thoughts on the subject matter. Refocusing medical education and CPD might help. We have succeeded in medicalising health care.


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