Overtreatment is defined as treatment that is unlikely to help a patient, which can stem from various factors, including a lack of alignment between the patient’s wishes and their physician’s clinical recommendations. Examples include prescribing a medication that a patient will not take or recommending a surgery that the patient does not want to undergo. Overtreatment is a major source of waste in the US healthcare system. A 2019 JAMA study, using government-based reports and peer-reviewed publications, estimated overtreatment costs $75.7 billion to $101.2 billion annually.1 This waste includes using branded medications instead of generics, screening and testing with little clinical value, and overuse of end-of-life care. Research on why overtreatment happens has suggested that part of it is due to miscommunication between the physician and patient, leading some to propose shared decision making as a way of addressing the problem.
Traditionally, the physician-patient relationship has been a hierarchical one, where the physician decides what treatment or medication the patient receives. Recently, the shared medical decision making has been gaining popularity and is now the preferred communication model. Shared medical decision making is a profoundly different way of approaching the physician-patient relationship. Physicians bring their medical expertise. Patients bring their experience of a disease and goals of treatment. Both parties have a discussion to reach a consensus on a treatment plan that both parties agree with, in contrast to the physician simply dictating what happens to the patient. Some goals of the shared medical decision-making model are to involve patients in their care to increase patient adherence, better the physician-patient relationship by creating an open line of communication, and prevent overtreatment.
There are two sides to address when considering the communication between physicians and patients: the content and delivery of the physician’s treatment plan based on expertise, and the patient’s desires and understanding of what the physician says. Some factors that have been researched in reducing overtreatment through shared medical decision making are educating patients on end-of-life care, understanding their prognosis, and the limitations and risks of treatment. The Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT) was a 2-year prospective observational study at 5 teaching hospitals in the US that educated 9105 patients hospitalized with life-threatening illness with the goal of reducing the overuse of medical treatment. Physicians and nurses who were specially trained in end-of-life care had conversations with patients about limitations of treatment and elicited their desires for end-of-life care. Despite this focused intervention, there was no significant difference in the use of hospital resources, suggesting training providers in conversations about treatment limitations is not sufficient to prevent overuse.2
Some other factors that contribute to overuse that were not addressed in the SUPPORT trial include patient beliefs, like the belief there is an effective cure or treatment for terminal illness, the perceived notion that choosing no treatment is “giving up,” and the glamorization of clinicians who help patients achieve miraculous survival.3 Often, the momentum of treatment can be so forceful that it is easier to continue escalating treatment rather than stopping. These complicated social forces need to be addressed on a broader level than the personal physician-patient relationship. Some possibilities include changing the messaging of healthcare systems to not dramatize miraculous survival and to identify treatment plans that, once triggered, typically lead to more healthcare utilization downstream. Additionally, there needs to be widespread cultural change to shift the focus of end-of-life care to quality of life instead of purely prolongation of life. These are changes that individual physicians cannot make on their own and will require the participation of society as a whole for widespread change.
References
- Shrank WH, Rogstad TL, Parekh N. Waste in the US Health Care System: Estimated Costs and Potential for Savings. JAMA. 2019 Oct 15;322(15):1501-1509. doi: 10.1001/jama.2019.13978. PMID: 31589283.
- The SUPPORT Principal Investigators. A controlled trial to improve care for seriously ill hospitalized patients. The study to understand prognoses and preferences for outcomes and risks of treatments (SUPPORT). JAMA. 1995 Nov 22-29;274(20):1591-8. Erratum in: JAMA 1996 Apr 24;275(16):1232. PMID: 7474243.
- Clapp JT, Schwarze ML, Fleisher LA. Surgical Overtreatment and Shared Decision-making – The Limits of Choice. JAMA Surg. 2021 Oct 13. doi: 10.1001/jamasurg.2021.4425. Epub ahead of print. PMID: 34643671.