• Overdiagnosis and overtreatment: the provider perspective

    Elsa Pearson, MPH, is a senior policy analyst at Boston University School of Public Health. She tweets at @epearsonbusph. Research for this piece was supported by the Laura and John Arnold Foundation.

    Overdiagnosis and overtreatment are widespread practices in the US health care system. Providers feel pressure from patients to “do something” and to protect themselves against malpractice. Patients feel pressure to go along with whatever providers say is best.

    None of this leads to better care quality or health outcomes.

    Overdiagnosis is defined as the “detection of psuedodisease,” or disease that will never cause the patient any issues. Overtreatment is treatment that provides no benefit and may even harm the patient. I recently wrote about this from the patient perspective, providing anecdotes and tips for patients to better advocate for themselves. Now let’s look at it from the provider perspective. Here are a few stories from providers who felt pressured to order tests or treatments that weren’t necessary.

    (Before going any further, it’s important to note that undertreatment is an equally serious concern. In particular, people of color often have to fight to get the attention and treatment they need from providers. The evidence of this is overwhelming.)

    Kendra Allan, internal medicine physician assistant

    A patient of mine hurt her hand. Based on my clinical assessment, she did not need any treatment beyond rest and ice and maybe some Tylenol. After explaining my recommendations, she requested opioid pain medication and an x-ray. I reiterated that both were unnecessary, but she was insistent. I ultimately ordered an x-ray which came back normal. Thankfully, we still avoided opioids.

    Amy Dickey, pulmonologist/intensivist

    I told a patient that I still wasn’t sure what was ailing him. “So, you’re telling me I just have to live with this?” he asked. That was not what I was saying, I told him, but I wasn’t going to start treatment until I had a firm diagnosis. I worry that some patients think there is a magic pill that fixes everything. Diagnosis takes time and treatment sometimes involves behavioral and lifestyle changes rather than medical intervention.

    Andrew MacGinnitie, pediatric allergist/immunologist

    I see many patients who suffer from chronic urticaria, or daily hives without a specific trigger. They are often convinced it is an allergic reaction (which is usually not true) and are insistent on allergy testing. It is sometimes difficult to convince them that testing is not actually necessary. I generally won’t test but do worry that some will go see another allergist because they are not satisfied with my care.

    Pushing back against overdiagnosis and overtreatment needn’t pit providers against patients. Just as patients should advocate for themselves, providers should practice evidenced-based medicine.

    Respect health literacy. Patients come to their providers with varying levels of health literacy. Kendra Allan, the physician assistant quoted above, notes that some patients want to know all the details of their diagnosis and treatment plan while others only want to know the bare minimum. Prioritize questions and discussion — treatment should not be a unilateral decision anyway — and learn to explain things on their level, be it with academic rigor or in simple language.

    Look to educate. Patients are not meant to have all the answers; after all, they wouldn’t need a provider if they did. However, this puts the responsibility on providers to educate their patients on diagnoses and treatment options. Tayler Simmons, a neonatal physician assistant, argues it is more valuable in the long run to educate her patients and their families on why she is not pursuing a particular test or treatment than it is to simply appease them and provide unnecessary care. Education also gives patients more realistic expectations of what sickness and recovery will look like, she says.

    Wait and see. Not all tests or treatments need to happen right away. Even the right treatment at the wrong time is still the wrong treatment. At best, this results in little to no benefit to the patient and, at worst, it actually harms her. If it’s not an emergency, providers should encourage “watchful waiting.” You can always order the test later.

    Say no. Not all tests or treatments need to happen at all. Providers should be comfortable saying no when pressured to order unnecessary imaging studies, consults, or prescriptions. Allan reminds us that a provider’s first mission is to “do no harm.” Saying yes to tests and treatments that aren’t indicated contradicts this, even if the patient insists.

    The American health care experience is full of unnecessary tests and treatments that provide minimal benefit to patients. New research in JAMA shows that receiving more of this “low-value care” isn’t associated with higher patient satisfaction either. Moving the needle on overdiagnosis and overtreatment will take time, but providers can do their part by thinking twice before placing orders.

     
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