Hard to Change a Long-standing Culture of Overtreating Patients
Some believe schools and health care workplaces should try harder to change the culture around overtreatment of medical conditions. Critics have alleged that physicians have gotten into the practice of over-testing and over-treating because they’re afraid of malpractice suits. Sometimes, too, this creates a cascade of testing that is seemingly never-ending for the patient.
“Some of the solution may be at the training level of health professionals,” Barnett Kramer, MD, MPH, director of the cancer prevention division at the National Cancer Institute, in Bethesda, Md., said. “The number one problem identified by medical historian Kenneth Ludmerer is insufficiency of training for uncertainty in medical school; his thesis was that [this] led to systematic overuse of testing and overtreatment. If neither the physician nor the patient are trained to think [about] and accept uncertainty, then almost always our medical culture is going to lean in one direction, so education in probabalistic thinking [is important].” He continued, another issue is “knowing when you don’t have to make a decision then and there. There are situations where we’re learning it’s uncertain what the best way to go is, but there’s pretty good evidence that waiting and seeing what the natural history of the disease is, is acceptable, and sometimes that’s very difficult.”
Kramer said a third consideration of inducing change “is to try to keep the discussion focused on what is known about the particular disease. There’s a famous saying that ‘If thought corrupts language, the opposite is certainly the case.’ So as soon as you have an entity with the word ‘cancer’ or ‘carcinoma’ in it, sometimes that shuts off the ability to really understand and get informed about what the disease really is.” He added, “There is some movement…to change the name of some of the things we call cancer. If we have enough biological information to know they don’t act like a routine cancer, that at least moves the word off the table and you can focus on what’s known and what’s not known and try to handle the uncertainties.”
Ranit Mishori, MD, MHS, a family physician and professor of family medicine at Georgetown University, said, “There are days when I go home and ask myself again and again and again, ‘Should I have ordered that test? I think I probably shouldn’t have, but is that patient going to sue me?’ God forbid they’ll be the one patient in 1,000 coming down with that rare form of prostate cancer.” Mishori explained a friend experienced this firsthand. “He followed all the guidelines about PSA [prostate-specific antigen] testing, and this one person was the person he didn’t test who ended up having prostate cancer and sued the heck out of him. Do you think my friend continued with not offering PSA testing to all his other patients? For a while, it was a very difficult decision for him.”
The doctor added that the probability of being sued seems to be based on location, making those in certain areas more reluctant to change. “If you’re in rural Arkansas, you’re less likely to be sued, but if you’re in Washington, D.C., and everybody and their sisters are lawyers, it’s something that goes through your mind a little bit more.”
Another problem is that one test often triggers a cascade of testing. Jacqueline Kruser, MD, a pulmonologist and critical care physician at Northwestern Memorial Hospital, in Chicago, said, “We see this for acutely ill patients. When they come to the hospital and are admitted to the intensive care unit (ICU), everyone who takes care of you is laser-focused on the acute problems that brought you there…Most importantly, they want to act quickly to fix them, and the environment is designed to fix things rapidly – we can get lab tests back in minutes and rush someone to the operating room in an hour.”
Kruser added, “What we worry about is, what about the patients who have different goals [than just getting things fixed] – they want to avoid invasive procedures or burdensome treatment, or they want to be with family, eating what they want to eat? All those cascading interventions might not accomplish those goals for that patient.”