From a patient perspective, it can be hard to see at first glance how too much care could be a problem. What’s wrong with an extra test, just to be safe? That almost sounds like a good thing.
But unneeded healthcare can be physically damaging. “Anything we do in medicine and healthcare has expected benefits and harms,” says Brenda Sirovich, a research associate at the VA Medical Center in White River Junction, Vermont, and the lead researcher behind the physician survey mentioned earlier. “Any time you have an intervention for a patient, no matter how small […] there is also the chance that it’s going to do some harm.” She points to the example of CT scans: for patients who are genuinely sick, they’re an important diagnostic tool. But they also expose patients to radiation, and when used too liberally, their harms outweigh their benefits.
Even for initial screening tests that pose no risk in themselves, there’s the problem of the “downstream effect;” if the first test produces an ambiguous result or a false positive, it can lead to more invasive testing that does carry substantial risk. “As you intervene on patients who have less and less reason to intervene and less and less chance of benefiting, you still retain that probability of harming them,” says Sirovich. “In a word, that is the biggest problem with doing too much—the risk of harm.”
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In some cases, the roots of the excess care are noble: Doctors just want to provide the best possible care for their patients. The operating assumption for many both inside and outside the medical field tends to be that if a little care does a little good, a lot of care will do a lot of good. Given the time constraints that many physicians are under, it can seem safest to default to over-ordering.
But there are several other major drivers of overutilization, as well. Experts debate exactly how much the threat of lawsuits influences physicians in their practice of medicine, but physicians themselves say that fear of legal challenges is a substantial factor in motivating them to provide too much care. (In Sirovich’s physician survey, malpractice was cited far more frequently than any other factor as incentivizing physicians to do more than they felt was clinically necessary.)
Skeptics challenge that physicians might not be in the best position to know exactly what motivates their own behavior. But a study published in Health Affairs this summer suggests that the malpractice effect is real. According to the report, doctors who acknowledge having a strong fear of malpractice are more likely to show a pattern of ordering aggressive diagnostic tests, and they’re also more likely to refer patients to the ER for treatment. This makes intuitive sense: Doctors are rarely asked if they did too much, but they are constantly questioned as to whether or not they did enough—and they know they can wind up in legal trouble if patients don’t think their care was sufficient.