Can More Be Done With Less?

It’s a central tenet of being a physician: Do all you can to help the patient. But so is "first, do no harm," and often, the harm comes from doing too much, too often. That’s the message from a growing number of physicians and organizations pushing for a sea change in how medicine is delivered, starting with the individual doctor.

In late April, many of the interested parties met in Boston to outline the problem and strategize on how to shore up evidence-based medicine and prevent knee-jerk test ordering and unnecessary treatment. "Avoiding Avoidable Care" was organized by the Lown Cardiovascular Research Foundation and the New America Foundation, and was cohosted by the Institute of Medicine.

The drivers of such avoidable or unnecessary care have been widely described: malpractice fears (so-called "defensive" medicine), and the economics of the health care system, in which volume is rewarded with greater income. But there also is "perhaps a misunderstanding of what is the ethical obligation to patients," said Dr. Vikas Saini, an organizer of the conference, codirector of the Lown Center, and president of the Lown Foundation.

Both patients and physicians tend to operate within the cultural framework that says more is better, he added. For physicians who are pressed for time, or uncertain, often "the best way forward is to order tests or pursue procedures," said Dr. Saini in an interview.

"If we start thinking differently about each of these [drivers], we’ll be going a long way towards reducing avoidable care," he said.

"We all have patients who have ideas that are completely outlandish," he said. However, most patients can be steered away from unnecessary procedures by clarifying what is appropriate and inappropriate, especially when the advice is tailored to an individual’s situation.

One strategy for the patient who demands certain tests is to talk about the potential for false positives. "Just pointing that out and reviewing the dilemma and the risk of triggering a cascade of more tests and procedures while increasing the risk of a side effect or adverse outcome [are] usually enough if the patient feels you have thought about it and given it a considered review," said Dr. Saini.

Often, the demands for tests or procedures are about seeking certainty and wanting to know that the physician cares, he said. Sometimes, it’s just about satisfying a patient’s curiosity; he or she may just "want to know."

But results can just as often lead to false knowledge. The key is to convincingly explain why conducting a test or procedure should be done only if it has the potential to change the course of care, he said.

Dr. Saini said that many patients show up at his office seeking a battery of 5 or 10 biomarker tests. The results don’t trigger recommendations for any specific therapy. "Instead, we recommend doing what they need to do anyway: eat right, exercise, and don’t smoke," he said.

To make progress in reducing unnecessary care, the physician has to be sensitive to the patient’s needs and be able to hold a conversation about what works and what doesn’t, said Dr. Saini. Patients will understand and accept what you have to say "if they feel you are on their side," he said.

This concept of shared decision making is important for another reason: It can help reduce malpractice risk. "The best protection is to be able to talk to the patient, understand their needs and concerns, and establish enough trust in the relationship" so that if something does not go according to plan, "there is not an immediate view that this is an error," said Dr. Saini.

And while physicians may interpret the Hippocratic oath to mean "do everything possible," that can actually create more harm. Clinical trials of screening tests or procedures discuss the "numbers needed to treat," but "we need to be more aware of the numbers needed to harm," he said.

Dr. Alan R. Schroeder, chief of pediatric inpatient services at Santa Clara Valley Medical Center, San Jose, Calif., said the problem is that the short-term harm from doing nothing often seems more tangible than the long-term harm. For instance, if antibiotics are withheld, the patient could get an overwhelming infection. The long-term threat of antibiotic resistance is far down the road, and not of great concern when the individual patient is being treated, said Dr. Schroeder, who has written and lectured on what he calls "safely doing less."

"Your job and your role and professional obligation is to do what is right for the patient."

This "more is better" concept takes root in medical school and is usually firmly ingrained by the time a physician goes into practice, he said. The thrust of medical education is that learning comes by way of making differential diagnoses; but generating those diagnoses requires extensive work-ups with lots of tests, or trying out different therapies to see what works, said Dr. Schroeder. Students and residents are taught that "if you miss something, you’ve failed miserably," he said.

Getting Out of a Practice Rut

As a teacher and a researcher, Dr. Schroeder has observed firsthand how those attitudes carry over into practice. He has taken a special interest in producing research that will help physicians practice less from habit and more from proven experience.

For instance, in 2008, Santa Clara Valley Medical Center decided to adopt recommendations from the U.K. National Institute for Health and Clinical Excellence 2007 clinical guideline that employed an algorithm for doing less imaging of the urinary tract in children who presented with a fever. As at most institutions, urinary tract imaging was routine for all febrile children with urinary tract infections, as a means of ruling out any underlying abnormalities.

But there was no clinical basis for imaging all children, Dr. Schroeder said. He studied the impact of the guideline and found that by letting the 90 pediatricians in the group know that it was acceptable to do less, the rates of imaging went down dramatically, he said. Also, the use of voiding cystourethrography and prophylactic antibiotics went down substantially "without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade vesicoureteral reflux (VUR)," according to his study (Arch Pediatr Adolesc Med. 2011;165:1027-32).

Similarly, at Atrius Health, physician behavior changed in response to some education and data showing that screening colonoscopy was being ordered at intervals that weren’t supported by any evidence, said Dr. Tom Denberg, vice president for quality and patient safety at Harvard Vanguard Physician Associates and Atrius Health. Atrius is a nonprofit alliance of six physician groups in eastern and central Massachusetts.

There was a huge amount of variation in how frequently gastroenterologists were urging patients to come back for repeat colonoscopies – even though there were at least a half-dozen guidelines that should have been informing their recommendations, said Dr. Denberg.

Why weren’t they following the guidelines? In part, because the physicians thought that the colonoscopies would give absolute certainty, and that if patients were brought back more often, nothing would fall through the cracks, such as a flat polyp, which is harder to detect, said Dr. Denberg.

Atrius brought in an expert GI specialist who reviewed the guidelines on screening intervals and also discussed the costs associated with repeat tests. The expert said that screening more often did not prolong life in most cases, or detect flat polyps more often. A malpractice attorney addressed the group, explaining that their litigation risk from not screening – even if a cancer developed – was minimal, especially if the physicians were following the guidelines and documenting procedures and results.

The conversations alleviated physicians’ concerns, and ultimately adherence to the guidelines more than doubled to acceptable levels, Dr. Denberg said.

Global Change Starts Locally

For many physicians – especially those practicing in a fee-for-service environment and in smaller practices that don’t have access to a lot of resources – there might not be much motivation to reduce unnecessary care. In those cases, "we have to appeal to physicians to do the right thing," said Dr. Denberg.

A motivated group of physicians – whether it’s 2 or 20 – who want to reduce inappropriate care can get together and conduct chart reviews to compare how they practice. This exercise illuminates variations in practice and lack of adherence to established guidelines. Reducing variation translates to less waste. Dr. Denberg said that it also gives physicians the leverage they need to dissuade patients from having certain tests or procedures that aren’t backed by clinical evidence, such as MRI for low back pain.

He also talks to primary care physicians about how much administrative time they can save by ordering fewer tests, especially when there is an absence of clear-cut symptoms or any clear clinical rationale. With every set of tests, the physician has to review the results and discuss them with the patient. Often, there are false positives, which require additional tests, or there are abnormal results that aren’t clinically relevant.

"A lot of that is avoidable," said Dr. Denberg.

Dr. Saini agrees that testing that is done in part to ward off malpractice suits often leads to more resource use, not more clarity. "Your job and your role and professional obligation is to do what is right for the patient," he said. "If you find yourself ordering a test or procedure because you think it could be a malpractice issue, then you’re thinking about yourself, not the patient."

Physicians are safe if they stick to the evidence, Dr. Schroeder said. "If you are doing less and it’s evidence based, your risk of malpractice goes down dramatically," he said.

Another key is to be skeptical of doing things just because it is an existing practice, said Dr. Schroeder. "Physicians need to keep challenging existing practices," he said.

It’s a central tenet of being a physician: Do all you can to help the patient. But so is "first, do no harm," and often, the harm comes from doing too much, too often. That’s the message from a growing number of physicians and organizations pushing for a sea change in how medicine is delivered, starting with the individual doctor.

In late April, many of the interested parties met in Boston to outline the problem and strategize on how to shore up evidence-based medicine and prevent knee-jerk test ordering and unnecessary treatment. "Avoiding Avoidable Care" was organized by the Lown Cardiovascular Research Foundation and the New America Foundation, and was cohosted by the Institute of Medicine.

The drivers of such avoidable or unnecessary care have been widely described: malpractice fears (so-called "defensive" medicine), and the economics of the health care system, in which volume is rewarded with greater income. But there also is "perhaps a misunderstanding of what is the ethical obligation to patients," said Dr. Vikas Saini, an organizer of the conference, codirector of the Lown Center, and president of the Lown Foundation.

Both patients and physicians tend to operate within the cultural framework that says more is better, he added. For physicians who are pressed for time, or uncertain, often "the best way forward is to order tests or pursue procedures," said Dr. Saini in an interview.

"If we start thinking differently about each of these [drivers], we’ll be going a long way towards reducing avoidable care," he said.

"We all have patients who have ideas that are completely outlandish," he said. However, most patients can be steered away from unnecessary procedures by clarifying what is appropriate and inappropriate, especially when the advice is tailored to an individual’s situation.

One strategy for the patient who demands certain tests is to talk about the potential for false positives. "Just pointing that out and reviewing the dilemma and the risk of triggering a cascade of more tests and procedures while increasing the risk of a side effect or adverse outcome [are] usually enough if the patient feels you have thought about it and given it a considered review," said Dr. Saini.

Often, the demands for tests or procedures are about seeking certainty and wanting to know that the physician cares, he said. Sometimes, it’s just about satisfying a patient’s curiosity; he or she may just "want to know."

But results can just as often lead to false knowledge. The key is to convincingly explain why conducting a test or procedure should be done only if it has the potential to change the course of care, he said.

Dr. Saini said that many patients show up at his office seeking a battery of 5 or 10 biomarker tests. The results don’t trigger recommendations for any specific therapy. "Instead, we recommend doing what they need to do anyway: eat right, exercise, and don’t smoke," he said.

To make progress in reducing unnecessary care, the physician has to be sensitive to the patient’s needs and be able to hold a conversation about what works and what doesn’t, said Dr. Saini. Patients will understand and accept what you have to say "if they feel you are on their side," he said.

This concept of shared decision making is important for another reason: It can help reduce malpractice risk. "The best protection is to be able to talk to the patient, understand their needs and concerns, and establish enough trust in the relationship" so that if something does not go according to plan, "there is not an immediate view that this is an error," said Dr. Saini.

And while physicians may interpret the Hippocratic oath to mean "do everything possible," that can actually create more harm. Clinical trials of screening tests or procedures discuss the "numbers needed to treat," but "we need to be more aware of the numbers needed to harm," he said.

Dr. Alan R. Schroeder, chief of pediatric inpatient services at Santa Clara Valley Medical Center, San Jose, Calif., said the problem is that the short-term harm from doing nothing often seems more tangible than the long-term harm. For instance, if antibiotics are withheld, the patient could get an overwhelming infection. The long-term threat of antibiotic resistance is far down the road, and not of great concern when the individual patient is being treated, said Dr. Schroeder, who has written and lectured on what he calls "safely doing less."

"Your job and your role and professional obligation is to do what is right for the patient."

This "more is better" concept takes root in medical school and is usually firmly ingrained by the time a physician goes into practice, he said. The thrust of medical education is that learning comes by way of making differential diagnoses; but generating those diagnoses requires extensive work-ups with lots of tests, or trying out different therapies to see what works, said Dr. Schroeder. Students and residents are taught that "if you miss something, you’ve failed miserably," he said.

Getting Out of a Practice Rut

As a teacher and a researcher, Dr. Schroeder has observed firsthand how those attitudes carry over into practice. He has taken a special interest in producing research that will help physicians practice less from habit and more from proven experience.

For instance, in 2008, Santa Clara Valley Medical Center decided to adopt recommendations from the U.K. National Institute for Health and Clinical Excellence 2007 clinical guideline that employed an algorithm for doing less imaging of the urinary tract in children who presented with a fever. As at most institutions, urinary tract imaging was routine for all febrile children with urinary tract infections, as a means of ruling out any underlying abnormalities.

But there was no clinical basis for imaging all children, Dr. Schroeder said. He studied the impact of the guideline and found that by letting the 90 pediatricians in the group know that it was acceptable to do less, the rates of imaging went down dramatically, he said. Also, the use of voiding cystourethrography and prophylactic antibiotics went down substantially "without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade vesicoureteral reflux (VUR)," according to his study (Arch Pediatr Adolesc Med. 2011;165:1027-32).

Similarly, at Atrius Health, physician behavior changed in response to some education and data showing that screening colonoscopy was being ordered at intervals that weren’t supported by any evidence, said Dr. Tom Denberg, vice president for quality and patient safety at Harvard Vanguard Physician Associates and Atrius Health. Atrius is a nonprofit alliance of six physician groups in eastern and central Massachusetts.

There was a huge amount of variation in how frequently gastroenterologists were urging patients to come back for repeat colonoscopies – even though there were at least a half-dozen guidelines that should have been informing their recommendations, said Dr. Denberg.

Why weren’t they following the guidelines? In part, because the physicians thought that the colonoscopies would give absolute certainty, and that if patients were brought back more often, nothing would fall through the cracks, such as a flat polyp, which is harder to detect, said Dr. Denberg.

Atrius brought in an expert GI specialist who reviewed the guidelines on screening intervals and also discussed the costs associated with repeat tests. The expert said that screening more often did not prolong life in most cases, or detect flat polyps more often. A malpractice attorney addressed the group, explaining that their litigation risk from not screening – even if a cancer developed – was minimal, especially if the physicians were following the guidelines and documenting procedures and results.

The conversations alleviated physicians’ concerns, and ultimately adherence to the guidelines more than doubled to acceptable levels, Dr. Denberg said.

Global Change Starts Locally

For many physicians – especially those practicing in a fee-for-service environment and in smaller practices that don’t have access to a lot of resources – there might not be much motivation to reduce unnecessary care. In those cases, "we have to appeal to physicians to do the right thing," said Dr. Denberg.

A motivated group of physicians – whether it’s 2 or 20 – who want to reduce inappropriate care can get together and conduct chart reviews to compare how they practice. This exercise illuminates variations in practice and lack of adherence to established guidelines. Reducing variation translates to less waste. Dr. Denberg said that it also gives physicians the leverage they need to dissuade patients from having certain tests or procedures that aren’t backed by clinical evidence, such as MRI for low back pain.

He also talks to primary care physicians about how much administrative time they can save by ordering fewer tests, especially when there is an absence of clear-cut symptoms or any clear clinical rationale. With every set of tests, the physician has to review the results and discuss them with the patient. Often, there are false positives, which require additional tests, or there are abnormal results that aren’t clinically relevant.

"A lot of that is avoidable," said Dr. Denberg.

Dr. Saini agrees that testing that is done in part to ward off malpractice suits often leads to more resource use, not more clarity. "Your job and your role and professional obligation is to do what is right for the patient," he said. "If you find yourself ordering a test or procedure because you think it could be a malpractice issue, then you’re thinking about yourself, not the patient."

Physicians are safe if they stick to the evidence, Dr. Schroeder said. "If you are doing less and it’s evidence based, your risk of malpractice goes down dramatically," he said.

Another key is to be skeptical of doing things just because it is an existing practice, said Dr. Schroeder. "Physicians need to keep challenging existing practices," he said.

It’s a central tenet of being a physician: Do all you can to help the patient. But so is "first, do no harm," and often, the harm comes from doing too much, too often. That’s the message from a growing number of physicians and organizations pushing for a sea change in how medicine is delivered, starting with the individual doctor.

In late April, many of the interested parties met in Boston to outline the problem and strategize on how to shore up evidence-based medicine and prevent knee-jerk test ordering and unnecessary treatment. "Avoiding Avoidable Care" was organized by the Lown Cardiovascular Research Foundation and the New America Foundation, and was cohosted by the Institute of Medicine.

The drivers of such avoidable or unnecessary care have been widely described: malpractice fears (so-called "defensive" medicine), and the economics of the health care system, in which volume is rewarded with greater income. But there also is "perhaps a misunderstanding of what is the ethical obligation to patients," said Dr. Vikas Saini, an organizer of the conference, codirector of the Lown Center, and president of the Lown Foundation.

Both patients and physicians tend to operate within the cultural framework that says more is better, he added. For physicians who are pressed for time, or uncertain, often "the best way forward is to order tests or pursue procedures," said Dr. Saini in an interview.

"If we start thinking differently about each of these [drivers], we’ll be going a long way towards reducing avoidable care," he said.

"We all have patients who have ideas that are completely outlandish," he said. However, most patients can be steered away from unnecessary procedures by clarifying what is appropriate and inappropriate, especially when the advice is tailored to an individual’s situation.

One strategy for the patient who demands certain tests is to talk about the potential for false positives. "Just pointing that out and reviewing the dilemma and the risk of triggering a cascade of more tests and procedures while increasing the risk of a side effect or adverse outcome [are] usually enough if the patient feels you have thought about it and given it a considered review," said Dr. Saini.

Often, the demands for tests or procedures are about seeking certainty and wanting to know that the physician cares, he said. Sometimes, it’s just about satisfying a patient’s curiosity; he or she may just "want to know."

But results can just as often lead to false knowledge. The key is to convincingly explain why conducting a test or procedure should be done only if it has the potential to change the course of care, he said.

Dr. Saini said that many patients show up at his office seeking a battery of 5 or 10 biomarker tests. The results don’t trigger recommendations for any specific therapy. "Instead, we recommend doing what they need to do anyway: eat right, exercise, and don’t smoke," he said.

To make progress in reducing unnecessary care, the physician has to be sensitive to the patient’s needs and be able to hold a conversation about what works and what doesn’t, said Dr. Saini. Patients will understand and accept what you have to say "if they feel you are on their side," he said.

This concept of shared decision making is important for another reason: It can help reduce malpractice risk. "The best protection is to be able to talk to the patient, understand their needs and concerns, and establish enough trust in the relationship" so that if something does not go according to plan, "there is not an immediate view that this is an error," said Dr. Saini.

And while physicians may interpret the Hippocratic oath to mean "do everything possible," that can actually create more harm. Clinical trials of screening tests or procedures discuss the "numbers needed to treat," but "we need to be more aware of the numbers needed to harm," he said.

Dr. Alan R. Schroeder, chief of pediatric inpatient services at Santa Clara Valley Medical Center, San Jose, Calif., said the problem is that the short-term harm from doing nothing often seems more tangible than the long-term harm. For instance, if antibiotics are withheld, the patient could get an overwhelming infection. The long-term threat of antibiotic resistance is far down the road, and not of great concern when the individual patient is being treated, said Dr. Schroeder, who has written and lectured on what he calls "safely doing less."

"Your job and your role and professional obligation is to do what is right for the patient."

This "more is better" concept takes root in medical school and is usually firmly ingrained by the time a physician goes into practice, he said. The thrust of medical education is that learning comes by way of making differential diagnoses; but generating those diagnoses requires extensive work-ups with lots of tests, or trying out different therapies to see what works, said Dr. Schroeder. Students and residents are taught that "if you miss something, you’ve failed miserably," he said.

Getting Out of a Practice Rut

As a teacher and a researcher, Dr. Schroeder has observed firsthand how those attitudes carry over into practice. He has taken a special interest in producing research that will help physicians practice less from habit and more from proven experience.

For instance, in 2008, Santa Clara Valley Medical Center decided to adopt recommendations from the U.K. National Institute for Health and Clinical Excellence 2007 clinical guideline that employed an algorithm for doing less imaging of the urinary tract in children who presented with a fever. As at most institutions, urinary tract imaging was routine for all febrile children with urinary tract infections, as a means of ruling out any underlying abnormalities.

But there was no clinical basis for imaging all children, Dr. Schroeder said. He studied the impact of the guideline and found that by letting the 90 pediatricians in the group know that it was acceptable to do less, the rates of imaging went down dramatically, he said. Also, the use of voiding cystourethrography and prophylactic antibiotics went down substantially "without increasing the risk of UTI recurrence within 6 months and without an apparent decrease in detection of high-grade vesicoureteral reflux (VUR)," according to his study (Arch Pediatr Adolesc Med. 2011;165:1027-32).

Similarly, at Atrius Health, physician behavior changed in response to some education and data showing that screening colonoscopy was being ordered at intervals that weren’t supported by any evidence, said Dr. Tom Denberg, vice president for quality and patient safety at Harvard Vanguard Physician Associates and Atrius Health. Atrius is a nonprofit alliance of six physician groups in eastern and central Massachusetts.

There was a huge amount of variation in how frequently gastroenterologists were urging patients to come back for repeat colonoscopies – even though there were at least a half-dozen guidelines that should have been informing their recommendations, said Dr. Denberg.

Why weren’t they following the guidelines? In part, because the physicians thought that the colonoscopies would give absolute certainty, and that if patients were brought back more often, nothing would fall through the cracks, such as a flat polyp, which is harder to detect, said Dr. Denberg.

Atrius brought in an expert GI specialist who reviewed the guidelines on screening intervals and also discussed the costs associated with repeat tests. The expert said that screening more often did not prolong life in most cases, or detect flat polyps more often. A malpractice attorney addressed the group, explaining that their litigation risk from not screening – even if a cancer developed – was minimal, especially if the physicians were following the guidelines and documenting procedures and results.

The conversations alleviated physicians’ concerns, and ultimately adherence to the guidelines more than doubled to acceptable levels, Dr. Denberg said.

Global Change Starts Locally

For many physicians – especially those practicing in a fee-for-service environment and in smaller practices that don’t have access to a lot of resources – there might not be much motivation to reduce unnecessary care. In those cases, "we have to appeal to physicians to do the right thing," said Dr. Denberg.

A motivated group of physicians – whether it’s 2 or 20 – who want to reduce inappropriate care can get together and conduct chart reviews to compare how they practice. This exercise illuminates variations in practice and lack of adherence to established guidelines. Reducing variation translates to less waste. Dr. Denberg said that it also gives physicians the leverage they need to dissuade patients from having certain tests or procedures that aren’t backed by clinical evidence, such as MRI for low back pain.

He also talks to primary care physicians about how much administrative time they can save by ordering fewer tests, especially when there is an absence of clear-cut symptoms or any clear clinical rationale. With every set of tests, the physician has to review the results and discuss them with the patient. Often, there are false positives, which require additional tests, or there are abnormal results that aren’t clinically relevant.

"A lot of that is avoidable," said Dr. Denberg.

Dr. Saini agrees that testing that is done in part to ward off malpractice suits often leads to more resource use, not more clarity. "Your job and your role and professional obligation is to do what is right for the patient," he said. "If you find yourself ordering a test or procedure because you think it could be a malpractice issue, then you’re thinking about yourself, not the patient."

Physicians are safe if they stick to the evidence, Dr. Schroeder said. "If you are doing less and it’s evidence based, your risk of malpractice goes down dramatically," he said.

Another key is to be skeptical of doing things just because it is an existing practice, said Dr. Schroeder. "Physicians need to keep challenging existing practices," he said.