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Making the case for “Less is More”

Last year, the New England Journal of Medicine (NEJM) published an editorial from cardiologist and NEJM correspondent Lisa Rosenbaum arguing that the “less is more” movement has gone too far. Rosenbaum claimed that the “crusade” to reduce overuse is leading to a slippery slope, where we risk not providing necessary care to people who need it. 

We published a rebuttal to Rosenbaum’s piece on our blog, detailing what we thought she got right and wrong in the editorial. Now, professors and co-directors of the Center for Medicine in the Media at the Dartmouth Institute, Dr. Steven Woloshin and Dr. Lisa Schwartz have published their own response in The BMJ. They argue that clinicians should not accept the status quo of ubiquitous overuse and underuse – they have a duty to their patients to act.

While Rosenbaum claims that the “less is more” movement is going too far, Woloshin and Schwartz  counter with evidence that reducing overuse is still necessary. Although recognition of overdiagnosis and overuse has increased over the past few years, we still waste trillions on unnecessary health care, guidelines are still expanding definitions of conditions without evidence, and health news media still report “enthusiastic coverage that stimulates greater uptake of new tests, treatments, and services,” Woloshin and Schwartz write. 

Our goal is to be like a “flexible Swiss Army knife,” in how we reduce overuse, rather than “an indiscriminate sledgehammer.”

In the face of rampant overuse and underuse, doing nothing is not an option. However, for the “less is more” movement to be successful we need to be deliberate and exact in how we target and tackle unnecessary care, write Woloshin and Schwartz. Our goal is to be like a “flexible Swiss Army knife,” in how we reduce overuse, rather than “an indiscriminate sledgehammer.” This is easier said than done, and will require a lot more research, resources, and conversations.

For example, we need more studies like ORBITA and CABANA to evaluate procedures that may not be as effective as previously thought. We also need more investment in trials like TAILORx, which found a method of identifying early-stage breast cancer patients who can safely skip chemotherapy.

On the resource side, we need more tools to support clinical decision-making, like these new deprescribing guidelines for benzodiazepines and antipsychotic medications, as well as more aids to help clinicians and patients make informed decisions, such as statin theaters and cancer screening decision aids.

“We will not get to better health care by standing still.”

And of course, conversations are key if we want to reduce overuse. Clinicians need time with patients to ask them about what their values and preferences, which can make a huge difference in whether or not they get the right care. But we also need to provide opportunities for clinicians to have meaningful conversations with each other to share stories of overuse and underuse. Lastly, administrators and policymakers interested in reducing overuse need to engage with clinicians, to understand the drivers affecting unnecessary care.

Woloshin and Schwartz acknowledge that the issue is not always black and white – that “less can be more, but it can also be less.” But that’s not a reason to accept the status quo. “We will not get to better health care by standing still,” they write.