Marilyn Fisher
My friend recently started feeling pain in her foot that has caused her to walk with a limp. Wanting to learn the source of the pain and receive relief, she scheduled an appointment with a podiatrist. She returned to our apartment after the appointment fuming. “The doctor didn’t examine my foot or even ask me to walk around! She just ordered a bunch of x-rays and then kicked me out!”
This conversation is similar to many I have had with friends and family who feel that their physicians are just “going through the motions,” immediately ordering tests or prescriptions without making an initial diagnosis or even taking time to hear the patient’s medical history. While a foot x-ray will help to inform my friend’s podiatrist about the cause of the pain, the way she acted was deeply concerning. Other doctors acting this way could cause serious harm to their patients.
When Does Treatment Become Harmful?
Consider the prescription of antibiotics. Many patients are used to receiving an antibiotic prescription from their doctor when they come in complaining of a cold or respiratory infection. These drugs are not innocuous, however. Unnecessarily prescribed antibiotics can weaken a patient’s immune system by killing beneficial bacteria in their gut that prevent infection, allowing the dangerous C. difficile bacterium to invade and cause serious symptoms. But according to the Centers for Disease Control and Prevention, 30% of all antibiotic prescriptions for respiratory infections are inappropriate. A 2020 study by Palms found that among visits for antibiotic-inappropriate conditions, antibiotic prescribing was highest in urgent care centers (45.7%) in comparison to EDs (24.6%) and medical offices (17.0%). Why is this? Urgent care centers are a source of immediate care and providers usually do not have a previous relationship with the patient. Instead of focusing on diagnosing the patient correctly or finding the best treatment, doctors are focusing on getting patients out the door.
Medical overuse, defined as the provision of medical services where the harm outweighs the benefits, has become an increasingly serious issue in the U.S. healthcare system, albeit one that goes largely unrecognized. Medical overuse first came into the national conversation when its contribution to the opioid epidemic was discovered. Aggressive prescribing of opioids to patients by physicians without proper consideration of the risk-to-benefit ratio resulted in increased development of substance abuse disorders. Renowned surgeon and author Dr. Atul Gawande admitted that most of the blame falls on doctors, saying in an interview with Vox: “We as a profession have caused an epidemic that is bigger than the HIV epidemic” and noting that he and his colleagues weren’t recognizing “the extent to which we were putting people at risk.”
A Commonplace Crisis
While the opioid epidemic is a devastatingly high-profile example, cases of medical overuse fly under the radar in clinics across the country, with examples of overtesting, overdiagnosis, and overtreatment being found across all areas of healthcare and across all patient populations. Ordering unnecessary tests that result in no beneficial information is not only wasteful financially but can be physically burdensome to patients if they are invasive. A 2020 study from Bhatia discusses the dangers of overtesting by showing how one low-value test can result in an unnecessary testing “cascade.” Twenty-two percent of low-risk patients in the study had a “low-value” ECG performed and, when compared with patients who had no ECG testing, had higher odds of subsequent stress testing, echocardiograms, and cardiologist consultation.
Overdiagnosis is a more unfamiliar term but is often seen when patients are diagnosed with a cancer that is slow-growing and has a low risk of death, resulting in patients experiencing increased anxiety and mental anguish. For example, the rate of diagnosis for thyroid cancer more than doubled from 1975-2005, but the mortality rates remained constantly low. Does identifying a disease that would have no effect on the patient do more harm than good for their mental health? Overdiagnosis also leads to dangerous overtreatment as procedural complications and expensive medical bills result in more negative consequences than the condition itself.
It is easy to jump on healthcare providers as the sole perpetrators of this crisis, but there are many factors that lead to the “more is better” mentality. One cause is fatigue from long hours and crowded waiting rooms. As the workday progresses, the number of prescriptions and test orders increases, according to a 2019 study by Neprash. Many physicians also cite fear of malpractice suits as a reason for medical overuse, with more tests and more procedures becoming a purely defensive measure. This incriminates patients in the problem as well. Medical overuse can be pushed by patients because of a need to feel like something “is being done.” But patients also need to realize that just because something is being done does not mean that it is beneficial, and that sometimes these futile procedures can be directly harmful.
What Can We Do?
Since both physicians and patients contribute to the problem of medical overuse, they both need to be involved in the solution. We can help physicians by advocating for mandatory breaks and regulations preventing working for long hours. Doctors need colleague support, so they have the time to spend with their patients and don’t feel rushed to get to the next in line. If you are the patient, it is your job to be informed. Do some research into the tests, procedures, and drugs available to you. Don’t be afraid to ask your doctor lots of questions! A doctor is not an infallible authority, but an expert who can still make mistakes. Be receptive if your doctor tries to communicate the concerns of medical overuse. Together, we can work to make healthcare safer, more efficient, and the most beneficial to patients.
Marilyn Fisher is a junior Biology major with a not-too-secret obsession with anything “retro”. In her spare time, she loves to watch classic movies (especially ones about health and medicine!) and practice her Mid-Atlantic accent. Until her next post, “Here’s looking at you, kid!”
References
Bhatia, R. S., Bouck, Z., Ivers, N. M., Mecredy, G., Singh, J., Pendrith, C., Ko, D. T., Martin, D., Wijeysundera, H. C., Tu, J. V., Wilson, L., Wintemute, K., Dorian, P., Tepper, J., Austin, P. C., Glazier, R. H., & Levinson, W. (2017). Electrocardiograms in Low-Risk Patients Undergoing an Annual Health Examination. JAMA internal medicine, 177(9), 1326–1333. https://doi-org.proxy-um.researchport.umd.edu/10.1001/jamainternmed.2017.2649
Centers for Disease Control and Prevention. (2021). Antibiotic Use: Current Report. https://www.cdc.gov/antibiotic-use/stewardship-report/current.html.
Kliff, Sarah. (2017). We Started It’: Atul Gawande on Doctors’ Role in the Opioid Epidemic. Vox. https://www.vox.com/2017/9/8/16270370/atul-gawande-opioid-weeds.
Neprash HT, Barnett ML. Association of Primary Care Clinic Appointment Time With Opioid Prescribing. JAMA Netw Open. 2019;2(8):e1910373. doi:10.1001/jamanetworkopen.2019.10373
Palms, D. L., Hicks, L. A., Bartoces, M., Hersh, A. L., Zetts, R., Hyun, D. Y., & Fleming-Dutra, K. E. (2018). Comparison of Antibiotic Prescribing in Retail Clinics, Urgent Care Centers, Emergency Departments, and Traditional Ambulatory Care Settings in the United States. JAMA internal medicine, 178(9), 1267–1269. https://doi-org.proxy-um.researchport.umd.edu/10.1001/jamainternmed.2018.1632
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