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April 30, 2019

What's behind 'the epidemic of overtreatment'? Blame medical training.

Daily Briefing

    Overtreatment is a pervasive problem in American medicine and some research suggests that the practice roots itself in doctors' habits early in their medical careers, Mara Gordon, a family physician, writes for NPR's "Shots." That's why Johns Hopkins Hospital is training residents not to overtreat, Gordon writes.

    Here are the most important factors for success—it starts with clinician-patient communication

    The problem of overtreatment

    "Medical education is built on the assumption that the more procedures or treatments doctors see and do, the more competent they'll be when they're independent," Gordon writes. And some research suggests that this early pressure to learn by doing more rather than less, may be fueling what some call an "epidemic of overtreatment" that increases health care spending and can subject patients to unnecessary invasive procedures, Gordon writes.  

    For example, a 2014 study published in JAMA found that doctors who trained in areas where patients underwent more tests and procedures tended to practice on their own in a similarly aggressive way.

    Another study by Joshua Geleris, an internist at Columbia University, looked at the number of tests medical residents in a New York residency program ordered during the 2016-2017 academic year and found that some residents ordered seven to eight times more tests than others.

    Geleris said it's difficult to know which number of tests is right, but the variation is a cause for concern. "They're just trying to get their work done and make sure the attending [physician] is happy the next day," he said.

    Gordon writes that she's fallen into the trap of overtreating a patient herself, recalling an experience when she ordered a colonoscopy for a young man with mild rectal bleeding. "I rationalized the risks of the procedure … because it would put both me and the patient at ease to know his symptoms weren't caused by something dangerous," Gordon writes.

    However, after speaking to a more experienced doctor, Gordon learned her patient's symptoms were almost definitely caused by hemorrhoids and that simply watching and waiting for a few weeks would have been safe.

    How Hopkins is teaching residents' new habits

    To break the overtreatment habit, some hospitals are raising awareness and are proactively teaching medical residents when less care may be the better option, Gordon reports.

    For example, a group of medical educators at Johns Hopkins Hospital in Baltimore aim to provide real-time data to residents about their test ordering habits—and how the compare with their peers.

    Pamela Johnson, a radiologist at Hopkins, said she's examining whether giving residents individualized report cards that break down theirs and their peers' ordering habits can effectively reduce the number of unnecessary CT scans for blood clots in lungs. She focused on this particular test because there are clear guidelines in place outlining when a CT scan is appropriate.  

    There's some evidence that this "peer pressure," has worked on fully trained doctors, Gordon writes. For example, Adam Cifu, an internist and professor at the University of Chicago's Pritzker School of Medicine, recalled learning that he had one of the highest prescribing rates in his department for prescribing broad spectrum antibiotics. Having that knowledge made him rein in his prescribing, Cifu said. "We're all ridiculously obsessive high achievers," Cifu said. "Seeing that I'm not in the 90th percentile or above kills me."

    Lenny Feldman, a physician at Hopkins who works with Johnson on the physician report card program, said the program aims to normalize a more reserved number of tests. "We have to break the cycle somewhere," he said (Gordon, "Shots," NPR, 4/19).

    Change how you communicate with patients

    5 myths physicians believe about patient experience

    Excellent patient experience is a critical piece of modern medicine, reflected clearly in outcomes. And more than amenities, clean rooms, or quiet during night, the factors that most inflect patient experience all relate to communication and coordination among the care team—factors that physicians are in a unique position to influence.

    Clinician-patient communication, leadership of the care team, and support and empathy for the patient across the unit are the most important factors for success, and they're all driven by the physician as the "Influencer in Chief."

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