A recent editorial in the New England Journal of Medicine (NEJM) from cardiologist and NEJM correspondent Lisa Rosenbaum catalyzed a heated discussion in the medical community about the movement to reduce overuse. Rosenbaum argued that the “less is more” movement is being oversimplified and risks going down a slippery slope toward underuse. (Read our response to Rosenbaum’s editorial on our blog.)
Among the many reactions to the piece on blogs and on Twitter, a particularly nuanced and insightful response came from a Right Care Alliance member, Dr. Saurabh Jha. Jha is an Associate Professor of Radiology at the University of Pennsylvania and a member of the RCA Radiology Council. He writes on The Health Care Blog and is active on Twitter @RogueRad. We sat down with Jha to talk about the “less is more” message and how to bring trade-offs into the conversation.
Lown Institute: In her editorial, Rosenbaum often refers to proponents of “less is more” as “crusaders” or “missionaries.” I thought this made the movement sound undiscerning, like some kind of “overuse police.” But you have a different view on it.
Dr. Saurabh Jha: I don’t think the term is derogatory or should be taken in a derogatory sense. You do need to have a crusade for “less is more.” You can’t have a place like Lown without having a mission. You can’t all be equally non-judgmental or nothing ever gets done. But when you have that type of mission, there are people who will point out there’s another side of the story. Dr. Rosenbaum did a good job of pointing out the other side, that you can’t make decisions based on probability, and lots of physicians feel that way.
Do you think Rosenbaum is right that “less is more” dominates policy discussions in health care?
For doctors, reducing overuse is the dominant message, particularly after Obamacare. But just because it’s the dominant message doesn’t mean it’s the dominant action. “Less is more” is not necessarily winning, and it’s not an easy battle to win.
I previously worked in England and Australia, in resource-constrained environments, so when I came over here and saw how much imagery was used, I was in awe at how quickly tests were done. But then I got annoyed by the waste, it’s like coming from a starving country and then seeing food get wasted on the table. And I see the harmful consequences of too much imagery and false positives, that don’t improve the quality of life. So on that point I would be at odds with Rosenbaum, because I think we need to be crusading.
Are doctors being made to feel guilty or defensive by the “less is more” message?
Many are. And the reason they are is because, regardless of how the narrative should have come out, they feel that it’s not the incentive structure being blamed, it’s their care for the patient. Right or wrong, the general feeling has been, “We blame fee-for-service” means, “We blame the physicians.” It’s the idea that they’re doing more because they can do more. This can put physicians on the defensive.
The reality is that fee-for-service doesn’t directly incentivize overuse but it does provide the infrastructure. Fee-for-service is like a six-lane freeway – you don’t have to speed but you can. The NHS system is more like a country road- even if you want to, you can’t go 80 mph. With fee-for-service you have an intolerance of uncertainty. If you miss a case with extremely subtle or vague symptoms, you remember it. You don’t have the luxury of thinking about every catastrophic scenario at the NHS.
How can we reframe overuse to not alienate physicians?
It’s hard for physicians to reduce overuse because they’re getting mixed messages – We tell doctors they have to reduce unnecessary scans and tests, but we also tell them it’s not okay to miss things. We have to tell people that you will occasionally miss things and that’s okay. It needs more than incentives, it needs a cultural shift.
We need to move away from talking about incentives and talk more about knowledge and uncertainty. This concept is more nebulous and doesn’t appeal to policy-makers. Policymakers want an easy answer to waste and overuse, but there isn’t one.
Targeting waste is often talked about as a health care “cure-all” – a way to save money while improving care, with no trade-offs. But we know there are trade-offs, so how do we bring this into the conversation?
When talking about overuse, there are two types of trade-offs. One is the trade-off you get when you have a constrained budget, like with an NHS-type system. In this system, providing low-value care means less money to spend on high-value care, so reducing overuse is a win-win. But in the US, it’s the opposite. Lots of hospital revenue comes from low-value care and this money often goes to pay for less lucrative, high-value care.
The trade-off Rosenbaum is talking about is the trade-off between overuse and underuse. The more you try and find disease, the more imaging you do and the more false positives you have. You can’t be equally good at finding disease and calling people healthy. If you want to move in one direction you’re either calling more healthy people diseased or calling more people healthy who are ill.
But the alternative is sticking with the status quo. Is that a better option?
I would say it’s worse having fewer false negatives and more false positives than more false negatives and fewer false positives. Not because I like missing things, but because the consequences of chasing false positives is too much. Also it’s not a one-to-one problem; for every false negative, there are more and more false positives. Looking harder and harder for disease provides diminishing returns.
We should be testing how much we can reduce overuse, in a constrained environment, like in the VA, Kaiser, etc. And see whether you can get doctors to do less, while accepting that doing less will occasionally lead to catastrophic misses. We can’t say, “You have to reduce overuse” but at the same time say, “You missed that diagnosis.” We have to reassure physicians they will miss things and that it’s okay.