We know there are many medical services that don’t offer clinical benefit and can harm patients. Why are we still doing these unnecessary tests and procedures? On the podcast “Turn on the Lights,” hosted by Kedar Mate and Don Berwick of the Institute for Healthcare Improvement, Lown Institute president Vikas Saini explains how overuse takes hold in medicine and how patients can protect themselves from the harms of unnecessary care.
Overuse, also known as low-value care, can take many forms. Everything from unnecessary routine orders of lab tests, to prescribing antibiotics for a virus, to stents for stable coronary disease. “If we could eliminate [these services], we’d be freeing up serious dollars and staffing for what really matters,” said Saini. Over $100 billion a year is wasted on overuse, researchers find.
If we know that certain tests and services are more likely to harm than help, why do we still do them? Some of it has to do with our volume-based system — doctors get paid more for doing more. But that’s not the whole story, said Saini, because overuse happens everywhere around the world, even in countries with different forms of reimbursement.
“[Overuse is] a problem deep in the culture of medicine. And maybe some of it is human nature. We all want a fix.”
Dr. Vikas Saini, president of the Lown Institute
We’re wired to assume that new technology is better, and that if something is “biologically plausible” — if it seems like it would work based on human biology — than it must work in reality, Saini explains. For example, doctors started using a device called a PA catheter to monitor heart pressure before there were clinical trials showing that it actually helped. Similarly, opening up clogged arteries with stents intuitively seems like it should work, but many studies over the past 20 years have shown that stents do not beat medical therapy for most stable heart disease patients.
“You’ve got a clogged artery, you go in, open it up, what’s not to like? Of course it must work. But it took 20-30 years to really figure out that the cases where it works are a limited subset.”
Dr. Vikas Saini, president of the Lown Institute
Doctors are also under a lot of pressure to make the right decision, which can drive doing more “just to be safe.” “The need to feel certain is powerful,” said Saini.
How can doctors reduce overuse, especially when there may be resistance from patients? “At the end of the day, it’s about trust,” said Saini. When doctors have an open demeanor and can take time to understand the patient and their situation, it builds trust. Our system sadly makes taking this time harder and harder, said Saini.
“Bernard Lown used to say that the paradox in healthcare is, the more time you spend with the patient, the more efficient you are.”
Vikas Saini, president of the Lown Institute
How can patients help protect themselves from overuse? It’s not easy, because the system is disempowering, and puts patients on a type of conveyer belt, said Saini. One way to help slow down that process is to ask your doctor questions like, “What is my alternative?”, “What happens in one year or five years if I do nothing?”, and “What is the harm of doing it? What is the worst thing that could happen?”
For more words of wisdom on overuse, listen to the full podcast!