When Doing Less Is Actually More

Imagine an innovation in modern healthcare that involves doing less—and patients are better off as a result. 

Gil Welch, M.D. of the Dartmouth Institute questions what he calls the widespread presumption that the best strategy to keep people healthy is through early diagnosis, and physicians and care teams are getting in on the conversation. 

Welch defines over-diagnosis as an asymptomatic abnormality or condition that will never progress or will regress, or will progress slowly enough that the patient dies of other causes long before the symptoms appear. 

The MemorialCare Physician Society has selected over-diagnosis as an area of focus, and the discussions occurring among our physicians challenge some long-held beliefs in modern healthcare. Raising the question of whether more medicine always results in better health runs counter to what providers and patients have believed. But if we’re truly committed to evidence-based medicine, it’s high time we look unabashedly at the evidence about when treatment helps and when it doesn’t. 

David Law, M.D., chair of MemorialCare’s physician society, reminds us that every test we order, every pill we prescribe and every procedure we conduct has the potential for harm. Too often, he points out, the potential benefits of treatment are exaggerated and the potential harms are not mentioned.  So it’s essential that best practice teams constantly seek the “true north” for evidence-based practices. It can be tempting for physicians to order a kitchen sink work-up of imaging and lab tests without considering what they’ll do about a negative or positive test outcome. Many of the incidental findings from such work-ups may not address the real problem requiring treatment. Jim Leo, M.D., medical director of best practice and clinical outcomes, promotes the benefits of additional alerts built into electronic medical record systems like Epic, alerting physicians that the test they’re ordering may not be valuable for the purpose in mind. 

Many physicians are faced with patients who want extensive tests and consults with no evidence to support the need. David Kim, M.D., medical director of the MemorialCare Medical Group, Los Altos, encourages patients to engage in a conversation with him so they fully understand what their choices are, rather than rushing headlong into a battery of tests they Googled. 

The pressure for physicians to practice defensive medicine and limit medical malpractice can reinforce indiscriminate over-diagnosis and over treatment. 

Potential changes to the Medical Injury Compensation Reform Act are on the ballot this November. MICRA currently caps the non-economic damages in a medical malpractice suit to $250,000. The ballot initiative includes an increase to non-economic damages to more than $1.1 million. 

If changes to MICRA are voted in, physicians will be under even more pressure to practice defensive medicine, increasing the likelihood of over-diagnosis and over-treatment. 

Mark Schafer, M.D., chief executive officer of MemorialCare Medical Foundation, encourages healthcare providers to use the Insitute of Healthcare Improvement's “triple aim” initiative as a compass to help avoid over-diagnosis. Is what we’re doing improving outcomes of care for specific populations, improving patients’ overall experience of care, and reducing per capita cost? Shining a light on over-diagnosis and engaging in an open dialogue has the potential to move the dial in each of those areas. 

It’s high time that all providers took a sober look at the benefits of extensive screening programs—getting more clarity about when they’re effective and when they’re not. We can all improve our patients’ experience by building relationships of trust and fully informing them of both the risks and benefits of tests and procedures. And we must all focus on redirecting resources currently spent on duplicative or irrelevant tests and procedures that are not clearly supported by the evidence.

Tammie Brailsford is executive vice president and chief operating officer for MemorialCare Health System in Orange and Los Angeles Counties  She is a member of the Payers & Providers editorial board.