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Avoiding Overuse is Key to Medical Professionalism
Deborah Korenstein, MD is one of the authors of the Professionalism Article Prize-winning article “Overuse of Health Care Services in the United States.” In her blog post, she details the impetus behind her research and how she discovered how closely the concept of “overuse” is tied to medical professionalism.
When my colleagues and I embarked on our review of overuse in the U.S. health care system, “professionalism” was not among the words we used to describe the project, despite the fact that notions of professionalism led us to focus on it. Rather, we thought a lot about:
- systematic review methodology;
- the research and policy implications of our work; and,
- the rather daunting task of reviewing over 100,000 article titles for potential inclusion (which I can report was not fun).
Our receipt of this year’s ABIM Foundation “Professionalism Article Prize” for our article “Overuse of Health Care Services in the United States” may seem surprising to some who think of physician professional behavior largely in terms of appropriate comportment and interpersonal interactions. However, avoiding overuse is, in many ways, fundamental to physician professional behavior.
Overuse of health services is defined as the use of services which are more likely to harm than benefit the patient. While cost to either the individual patient or to society as a whole is a legitimate harm, the harm from overused services is more commonly real harm to patient health. This includes:
- side effects or toxicity from medications;
- complications of diagnostic or therapeutic procedures; and,
- downstream harm from falsely positive tests in the form of complications from unneededdiagnostic testing and problems related to over-diagnosis of benign conditions.
Indeed, despite the fact that overuse is commonly discussed in the context of cost savings (and often conflated with the unmentionable — “rationing”), overuse is primarily a problem of quality of care and patient safety. If you examine the definition of professionalism, the avoidance of overuse is at the very core of what it means to be a doctor.
Medical Professionalism in the New Millennium: A Physician Charter describes three fundamental principles of professional behavior: the primacy of patient welfare, social justice in the health care system and patient autonomy. Avoiding overuse falls under all three of these principles.
First, avoiding interventions which are more likely to harm than help the patient is clearly central to the idea of patient welfare. Physicians must be mindful of the fact that all tests and treatments carry at least a small risk of patient harm. When those interventions are very unlikely to benefit the patient, the balance can easily tip toward net harm. Reasonable physicians can certainly disagree about the magnitude of potential benefit or harm from an intervention for an individual patient. Yet, all should agree to avoid interventions that are more likely to harm the patient than benefit them.
Similarly, the principle of social justice includes the fair distribution of resources. Health care spending with no potential benefit—even in the absence of substantial potential harm—is therefore unprofessional in its misuse of limited resources. Even the principle of patient autonomy, which physicians may use to argue for unhelpful interventions requested by patients, notes the primacy of patient decision-making as long as it does not “lead to demands for…inappropriate care.” Clearly, then, avoiding overuse is a major responsibility of all physicians.
But why bother talking about it? One of the major findings of our paper was that overuse has been understudied; for many services, we know nearly nothing about the frequency of overuse or the associated harms. There are many potential reasons why overuse has not been a subject of adequate investigation, including how difficult it is to study. Beyond the technical challenges though, overuse research has not been pursued or well-funded because talking about overuse makes doctors uncomfortable. We doctors want to feel like we can do things to help people and we want to offer tests and treatments to patients who ask for answers to their health problems; we don’t like not doing things.
Also, while potential benefits of tests and treatments are often tangible and easy for both patients and doctors to appreciate, potential harm from unnecessary tests can be abstract and difficult to quantify. There is an inherent tension when physicians consider overuse in terms of justice in the health care system and costs to society. Because physicians are always caring for an individual patient, notions of societal justice must be balanced with the principle of patient welfare (advocating for the individual), and in our system of seemingly unlimited resources, the harm to the system of unneeded care are difficult to weigh.
Because of the challenges of talking about overuse and in spite of the discomfort it can induce, conversations about overuse are important. Overuse of medical services threatens the health of our patients both individually and across our system of care. Working to minimize overuse is core to our professional identities as physicians. We are happy that our paper has contributed in a small way to this important ongoing dialogue and, just maybe, to professionalism itself.
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