Reasons why doctors overtreat and overtest

The New York Times recently had an important and provocative piece, “Overtreatment Is Taking a Harmful Toll.”

The title is a bit misleading. The article focuses more on overtesting. We test too much and we treat too much.

The article, while mostly accurate, does not really explain the reasons for the problem. Unless we can accept and understand the underlying reasons for these problems, we cannot successful correct these problems.

Let me suggest the major reasons for overtreatment and overtesting. Prior to writing about each one, I do want to see if readers can suggest any more or disagree with the list.

Our payment system that pays for each thing (i.e., diagnostic tests, visits) encouraging us to do more things. We get paid the same when we spend less time with the patient and order more tests.

Advances in technology, by which we have better imaging and more laboratory tests. Sometimes the tests are too good, and suggest that we do more tests. Perhaps we should do more careful history and physical exams and do less testing.

Guidelines based on single diseases. We use too many medications to achieve targets that may help a disease but hurt other diseases. Too often we have guidelines that do not give us enough “leeway” to individualize therapy.

Patient demand. Patients think they need an MRI of the head, because a friend said so. That friend knows someone whose 2nd cousin had a rare brain tumor found because of an MRI, thus you must get an MRI.

Malpractice fears. Studies never document this, but all physician know that it is true. This is especially true in emergency departments. Every time I write this my comments fill up with emergency physicians justifying all the studies they do. But ask any hospitalist about excess CTs in the ED. The first abdominal CT for cryptic severe pain makes sense. Perhaps the second, but certainly not the 5th, 6th and 7th.

Marketing from big pharma leads to more expensive drugs and increased patient demand for those drugs. This occurs especially from direct to consumer advertising.

Lack of information from other physicians. Our obsession with privacy and HIPAA decreases the sharing of important medical information across sites. Every time a patient sees another physician the order the same tests because it’s easier than trying to get the old results.

I am certain that I have not been totally inclusive in my list. This is really a multi-faceted problem.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

    Direct Primary Care, by its very design, helps to curb some of the above reasons for overtesting and overtreating. Because our doctors at MedLion are not paid per visit or per procedure, ordering extra tests is avoided. Revenues are generated via monthly membership volume at $59 per month per patient. Our MedLion doctors are independent private practitioners, and though they are licensed to use our model, they are financially incentivized by MedLion to improve upon parameters set for chronic conditions. Our malpractice rates are less because we spend more time with our patients (a perk in itself) and because each MedLion doctor carries a maximum of 1,500 adult patients in our model (half the national average). Our goal is to provide high-impact, high-quality primary care to prevent downstream complications and hospitalizations, which also drive up healthcare costs.

    • kjindal

      advertisements dressed up as responses have no place on this blog – can these be screened out by the site administrator?

      • http://www.kevinmd.com kevinmd

        Most of them get screened out, but obviously a few get through. Please flag suspicious responses and they will be dealt with.

        Kevin

        • kjindal

          thanks Kevin

        • http://www.facebook.com/people/Samir-Qamar/1843287708 Samir Qamar

          Sorry about that Kevin, got carried away by the success of our model and how it impacts the article. Please remove my original comment and I’ll post something more general.

  • http://www.facebook.com/claudia.herbei Claudia Herbei

    This is really pathetic! Are you a practicing physician by the way?

  • Homeless

    I don’t ask for things I don’t need. The rest of the list provides me with enough incentive to do my own research because I cannot trust my doctor to make the right decision for me. On several occasion I felt the recommendation from a doctor was enhance his bottom line.

    • KMarton

      If you’ve never asked for an antibiotic for a cold or an x-ray for a back ache or a CT scan for a headache or a chest xray for a cough (all are things that are usually not needed), then you are in the minority and good for you. .
      Assuming that you can’t trust your physician, however, is not in anyone’s best interests. Instead you might try more probing questions when you next see that person.

      • Homeless

        It’s clear that what is in my best interest isn’t a priority in medicine.

  • http://www.facebook.com/drtaher Taher Kagalwala

    The problem with modern medical systems all over the world is defensive practice to avoid malpractice suits. Add to that the modern problem of patients accessing medical information of dubious quality from the internet (read Wikipedia) and you will see why doctors are forced to go on the back-foot. Gone are the days when patients listened to their doctors and believed in them. Nowadays, the patient is more likely to retort that he/she knows more about his/her illness than you simply because he has more “recent” (albeit unauthenticated) information.

  • KMarton

    This list is pretty complete, but I’d add 2 more reasons–both related to the payment system.

    1) lack of time. physicians are paid to see more patients. if they take the time to discuss the pro’s and cons of a test, they essentially lose money. It’s easier to spend 20 seconds filling out a requisition.

    2) Conflict of interest. If a physician owns the testing equipment, he/she will use it more often than if that physician refers the patient to an outside facility.

  • James W. Denham

    In our country we treat based on possibilities. Almost, if not, everywhere else physicians treat on probabilities. Reform malpractice litigation and much of this would change.

  • katerinahurd

    It is obvious to me that although you rasised reasons for why doctors over treat and over test, as a patient, I would characterize them as justifications for the unethical conduct of physicians toward patients. According to the points you made, the ethical practice of medicine dosn’t depend on the financial incentives that the doctor might recieve, the inability of physicians to practice medicine without being victimized by the medical- industrial complex, the inability of the doctor to refuse to practice concierge medicine, the lack of communication among physicans and the fear of physicians of confronting their professional societies that set guidelines for the treatments of single diseases. At the end, the physician is still victimized by the marketeers of big pharma, but no physician turns down an invitation to reside on the board of large pharmaceutical companies. Considering all the right issues you raise, the underlying ethical principle that is violated is, first do no harm. The art of medicine has been practiced for centuries without the advances in technology and the marketing of drugs by big pharm. As you suggest, return to basics such as exercising the art of listining to take a medical history from the patient and the significance of physical exam can restore an ethical interaction between doctor and patient and a mutual respect, since the patient doesn’t feel like he is treated like an experimental guinea pig and the physician is willing to aknowledge the futility of certain medical interventions. I look forward to your response.

  • http://twitter.com/DocRockne Michael Mirochna, MD

    By BigPharma marketing, I think you mean drug reps and free lunches. Remember the movie “The Lost Boys?” The vampires can only come into your house if you invite them. Stop inviting them. Turn away the free lunches that your patients are paying for. Use four dollar lists. Tell patients why the new drug is so much better in absolute benefit, not relative benefits. Let them choose if they want to have it. You might just save your patient from the next vioxx, avandia, or maybe just an expensive drug that doesn’t do much, I’m talking about you Tekturna.

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