Doctors’ fear of omission vs. commission

February 23, 2016

By Margie Coloian, MSJ

An interview with Rita Redberg, MD
Dr. Redberg, chief editor, JAMA Internal Medicine and director, Women’s Cardiovascular Services, University of California, San Francisco, will kick off Research Day at the 4th Annual Lown Institute Conference, April 15-17, at the JW Marriott Chicago.

How long have you been interested in the topic of excessive medical tests and treatments?

I’ve been interested since medical school, having worked with John Eisenberg, MD, who led the Agency for Healthcare Research and Quality.  He was a global leader in quality improvements and dedicated his career to evidence-based research in health care decision-making. John inspired us to think about whether it was necessary to order a test and to ask whether the information gained from that test would improve the patient’s management or outcome. He also made us question if the ordered test was the only way to obtain information that would not be available through clinical evaluation.

Do those lessons still ring true?

Yes, today we spend an enormous amount of money on health care in this country, and yet 33 million Americans don’t have health insurance. They don’t have access, and there are also vast pockets with limited access to care. There is so much spent on health care; there is so much waste in the system. And we don’t rank high on longevity or outcomes.

Given the high cost of care, why do you think that doctors continue to practice aggressively?

There are probably lots of reasons for that. Everyone is oriented to ‘more is better’ in health care. And doing another test ‘can’t hurt’ because doctors love technology. Doctors are concerned more about omission than commission—suffering that comes from something you haven’t done, rather than something you have done. Additionally health systems earn more when more is done in their institutions.

Is there any particular specialty that overuses more than others?

I think cardiology because it’s better studied, and because we use lots of technology.

In your view, what can be done to curb overuse?

Lots of things can be done. The Lown Institute and the Right Care Alliance are working toward that end. I think we should be training younger doctors and students to recognize overuse, and older doctors as well. Changes are happening. We are moving away from fee-for-service toward value-based payment systems and accountable care organizations, whose conclusions are not yet known.

What are you looking forward to as you keynote the Lown Institute Conference’s first Research Day?

I’m hoping to see an increased awareness for overuse and the new approaches that are being discussed. I’m always interested in learning what is working and the various ways everyone thinks about overuse. At UCSF, we have had discussions recently about “high value care” and I was fascinated with the different groups and approaches. I think the Lown conference is a very important conference. I support its goals and believe it is changing the national conversation around right care. I still remember the first Lown conference and all the great energy that was around it.