Less Is More in Medicine?>

Less Is More in Medicine

by John Swartzberg, M.D.

The practice of medicine, especially in the U.S., went through a vast expansion starting in the 1960s, thanks largely to advances in the diagnosis and treatment of countless conditions, often involving increasingly sophisticated technology and medical spe­cialists. The last 50 years have been a boom time for many industries, but health care has outpaced nearly all of them, growing from about 6 percent of our GDP in 1965 to 17 percent today. A lot of good has come from this boom, which has played a key role in the nine-year increase in U.S. life expec­tancy during this period.

Still, life expectancy is higher and many health outcomes better in quite a few industrialized countries that spend far less per person on medical care than we do. Increasingly, health care experts have been blaming this situation in part on our tendency to overtest, overdiag­nose, and overtreat, which is not just wasteful but also often harmful.

This has now led to what’s called the less-is-more movement, whose goal is to reduce the use of practices that offer little or no value, that put patients at unnecessary risk, and that often result in a cascade of follow-up care for conditions that will never become life-threaten­ing. Researchers estimate that such practices account for a large part of the hundreds of billions of health-care dollars wasted every year.

A few years ago we reported on a national survey in which four out of ten primary care doctors said that patients in their own prac­tices were receiving too much health care, and half felt that other doc­tors, particularly specialists, were similarly doing unnecessary testing and treating. The reasons cited included malpractice concerns, a desire “just to be safe,” patient insistence, and having inadequate time to spend with patients (it’s often quicker to order a test or prescribe a drug than to spend time explaining how doing either isn’t necessarily better). Of course, doing more diagnostic testing and treatment often means more income for health care providers because our medical system rewards volume rather than value.

The less-is-more movement took off in 2012 with the Choosing Wisely campaign, which has enlisted more than 70 medical specialty groups to name five or ten tests, treatments, or procedures used in their fields that are not evidence-based and are more likely to do harm than good (many questionable procedures haven’t yet made the lists). Major medical journals such as JAMA Inter­nal Medicineand BMJhave published series of articles critiquing low-value practices and medical overuse.

I expect that this movement is causing many health care providers to question some of the ways they’ve been practicing medicine and encouraging patients to ask questions about tests and procedures.

I became more optimistic about all this after reading an article by Dr. Atul Gawande in the New Yorkerin May. It was a follow-up to an influential article he wrote six years ago about the problems of unnec­essary health care in McAllen, Texas, where Medicare costs were among the highest in the country. Since then, Medicare costs have flattened across the country, but he found that they’ve dropped dra­matically in McAllen, while many health outcomes have improved.

Dr. Gawande’s earlier article apparently helped spur the changes in McAllen, as has the Affordable Care Act, which among other things encourages doctors to form “accountable-care organizations” and rewards them for providing higher-value services, thus improving out­comes and saving money. “We’re finally seeing evidence that the system can change—even in the most expensive places for health care in the country,” Dr. Gawande concludes. He is a wonderful writer and thinker, and I recommend his article highly.