Monday, May 18, 2015

Overuse of health care: can -ologists help themselves?

In a previous post, I reviewed a terrific conference presentation by four orthopedic surgeons on what should have been on the American Academy of Orthopaedic Surgeons' "Choosing Wisely" list instead of the timid and low-impact items that the society actually published. In the question-and-answer session that followed, someone asked if the presenters had shared their evidence-based list with their society's leaders at one of their national meetings. They hadn't. "We would probably have gotten tossed out of the building," one joked, then added more seriously, "A lot of our members make their living by doing these procedures day in and day out."

Lest I seem to unfairly single out orthopedic surgeons and urologists for turning a blind eye to evidence that refutes long-standing medical practices, a research letter published in JAMA Internal Medicine found that specialist societies (membership organizations of physicians whom my friend and family medicine colleague Richard Young dubs "-ologists") are generally likely to resist reversals of practice. In 20 examples of high-quality, high-profile studies that provided evidence for medical reversals, nearly half of official -ologist society responses defended the practice, an effect that was more pronounced when a reversed practice was rated by the authors as of high importance to members of the responding society (e.g., mammography to radiologists).

Resistance to what physician and health services researcher Peter Ubel calls "de-innovation" is driven by more than just fear of declining income. In a Health Affairs commentary, Dr. Ubel identified several psychological biases that cause -ologists to reject new evidence that contradicts established practices: preconceptions (tendency to favor information that confirms prior beliefs), clinical experiences, mistaking association for causality, and reduction of cognitive dissonance.

Primary care clinicians are not immune to these biases, but a family physician's greater tolerance for uncertainty may be advantageous in adapting to medical reversals and reducing overuse of low-value (or no-value) care, such as PSA screening for prostate cancer. In contrast, -ologists may perform unnecessary tests in attempts to eliminate uncertainty, such as an unenhanced CT scan to "rule out" a 2-mm nonobstructing kidney stone that would not change management:

What drives doctors to order tests? We order tests because we must know why. Anything can be known morphs into everything must be known. ... We order CTs because we can. The CT heals us, and our patients. Uncertainty ails. Our intolerance of uncertainty is neither congenital nor stochastic. Our dislike of uncertainty has grown with the availability of imaging. It has reached its apotheosis because of rapid door-to-CT time, the removal of barriers to ordering, and the speed with which reports are rendered. ... So much waste can be avoided by using probability and numbers and applying judgment—the components of rational medical decision making.

Although the relationships between providers of health care, costs, and overuse are complex, recent evidence supports associations between comprehensive primary care and lower costs and higher continuity of care and less overuse. Given these findings, it's not surprising that Atul Gawande's latest New Yorker piece, "Overkill," concluded that tackling overuse in health care meant supporting and empowering clinicians whose generalist training, experience, and tolerance for uncertainty makes them best suited to replace unnecessary care with necessary care: family physicians.

2 comments:

  1. In my own practice as an infectious diseases consultant, I see the opposite effect. That is, I far more commonly write recommendations to discontinue antibiotics that to start them. Because of our familiarity with the disease processes we treat, we often are able to cancel echocardiograms in bacteremic patients, as well as other imaging studies that do not add value to the care of the patient. Moreover, our understanding of the pharmacokinetics of antibiotics allow us to recommend regimens that are less complicated, less costly, and less invasive that the regimens at the time of consultation. Unfortunately, in the race to discharge patients form the hospital, we not uncommonly find a PICC line already inserted in a patient who could be treated with oral therapy.

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  2. Thank you, Mike. I agree that discontinuing unnecessary care is a valuable role for ID docs, especially in the inpatient setting.

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