A Simple Way for Physicians to Take Action Against Overtreatment

By Christopher Moriates, MD  and Neel Shah, MD MPP

“The plural of anecdote is policy,” medical historian and health policy expert Dan Fox famously stated. Sometimes a good anecdote can be worth a thousand academic papers in motivating change and right now healthcare is at an important cultural crossroads.

In the current medical world the default is for more healthcare – more testing, more treatments, more surgery, more stents, and more screening. The public understandably, and often correctly, infers that more must be better when it comes to medicine. Physicians have not been able to effectively explain the paradox that in some cases more healthcare does not equal more health, and in fact it sometimes means the opposite.

But we physicians have seen the harms of overtreatment. We have seen patients go on dialysis machines because the contrast from a CT scan destroyed their kidneys. We have seen patients suffer from severe bacterial infections that develop following the inappropriate use of antibiotics (e.g. C. Difficile colitis). We have talked about patients in our “M&M” (Mortality and Morbidity) conferences that have died on the cardiac cath table undergoing a procedure that they may not have needed.

It is time for us to tell these stories on a broader scale. The innate power of storytelling has been successfully harnessed to improve care and advance medical culture before. More than a decade ago the infamous analogy likening the number of deaths due to medical errors to a jumbo jet crashing every day gave readers a disturbing visual that drew a visceral response in a way that raw numbers just never will. It helped galvanize the professional and public momentum behind the patient safety movement.

More recently, stories have been paired with data to help drive a new movement that encourages appropriate, rather than just “more”, care. Atul Gawande’s anecdote about unwarranted Medicare spending in McAllen, Texas started as a magazine article; it has now become a call-to-arms that was required reading in the Obama White House. The Costs of Care Essay contest started as an effort to encourage patients and their caregivers to think about opportunities to improve value; it has now become a robust crowdsourcing mechanism that added necessary clinical detail to the Institute of Medicine’s Best Care at Lower Cost report.

While we modern physicians all (rightfully) worship around the altar of evidence-based medicine and data-driven decision-making, our hearts are still very much shaped by our own stories, experiences, and those that we hear from our colleagues. Morning reports, conferences, and resident workrooms buzz with the harrowing tales of “I have this patient who…” and “I once saw…” As a result, case-reports hold an important place in the history and development of our medical knowledge.

Towards this goal, JAMA Internal Medicine has created “Teachable Moments,” a new series for trainees at all levels to tell the stories from the frontlines of healthcare of when overuse causes harm.

Together we can change the national narrative and lead to smarter, safer and more thoughtful healthcare that once again is aimed at achieving our shared goal of actually improving people’s health.

This post is cross-posted at the JAMA Internal Medicine Blog.

Christopher Moriates, MD (Twitter: @ChrisMoriates) is an Assistant Clinical Professor at UCSF. He is the Co-Chair of the UCSF Division of Hospital Medicine High-Value Care Committee. He is a Series Editor for “Teachable Moments,” JAMA Internal Medicine.

Neel Shah, MD MPP (Twitter: @Neel_Shah) is the Executive Director of Costs of Care and an OB/GYN at Harvard Medical School. He is a Series Editor for “Teachable Moments,” JAMA Internal Medicine.