Are demanding patients driving the epidemic of unnecessary medical care?

Our health care system in the United States is notorious for providing a lot of unnecessary medical care — something we’ve written about extensively.

Doctors may provide that unnecessary care because they perceive that patients are expecting or requesting it.

If health care professionals don’t provide the aggressive care that patients believe they require, the thinking goes, patients won’t be satisfied and the doctor-patient relationship will suffer. Plus, the patient will just go to another provider who’ll perform the requested services anyway.

But does that explanation hold water?

Patients understand: More care is not better care

Preeti Malani, MD

The latest report from the University of Michigan’s National Poll on Healthy Aging, which recently surveyed some 2,000 US adults between the ages of 50 and 80, casts doubt.

Preeti Malani, MD, who is a professor at the University of Michigan and director of the polling effort, summarized some key findings from the report together with co-author Jeff Kullgren, MD, on the Health Affairs blog. (Malani is also an expert story reviewer for HealthNewsReview.org.) They wrote:

Only 14 percent of poll respondents agreed that more medical treatment is usually better. In contrast, more than half (54 percent) felt health care providers often order medications, tests, or procedures that patients don’t really need. One in six (17 percent) reported that in the last year a health care provider had recommended a medication, test, or procedure that they felt they did not need.

Not only do many older Americans report that they receive care perceived as unnecessary, the results show, but those patients would likely go along with clinician efforts to avoid prescribing unnecessary tests and treatments. Malani and Kullgren write:

When clinicians explained to older adults that they did not need a service they had requested, nine in 10 of these patients reported that they understood the clinician’s explanation. In contrast, when an older patient’s health care provider recommended a test or medication that the patient felt was not needed, nearly half proceeded with the recommendation regardless.

So nearly all respondents understood the explanation as to why they didn’t need a test or treatment, and more than half went along with tests or treatments they thought they didn’t need simply because the doctor ordered it. This suggests that the medical community has more influence over patient behavior than is widely acknowledged.

‘Not really a good excuse’

“It could be a little bit of a generational thing,” Malani said in an interview, noting the older cohort they surveyed may see physicians as more of an authority figure than younger patients.

Regardless of the reason, she said the results suggest the conventional wisdom about patient expectations often doesn’t apply. “When people say, ‘I have to order that test because otherwise Mrs. Jones won’t like it,’ that’s not really a good excuse for doing it,” she said.

It’s a conclusion backed up by some other research on physician-patient interactions. For example, pediatricians may perceive an expectation that antibiotics will be prescribed even when drug treatment is not directly requested. Clinicians who perceive such an expectation are more likely to prescribe antibiotics unnecessarily.

Obstacles to shared decision-making

Ade Adamson, MD, an assistant professor of dermatology at the University of North Carolina Chapel Hill who studies both over- and under-use of medical care, seconded the need for more thoughtful communication in the health care system. “I think more of these conversations should be had between patient and provider,” he said in an email. “More patients should speak up. Joint decision making, grounded in evidence, should be the ideal we strive for.”

But he cautioned that “what the patient versus the physician interpret as low value are not always the same. As result, when entering these conversations, it is sometimes easier to order the service than to have a debate/conversation as to why a certain procedure/test/medicine is of low-value.”

Adamson gave the example of certain medical interventions that are not recommended for older adults simply because patients above a certain age are not expected to live long enough to benefit from the test or treatment.

“If the reason for withholding a certain service or medication that a patient comes to expect is purely because of their age, some providers may not want to have those types of uncomfortable discussions,” Adamson said.

The need for ‘Choosing Wisely’

Malani agreed that there are many obstacles to better clinician-patient communication. She said that programs like Choosing Wisely, which aim to educate patients and consumers about wasteful medical care, are critical to facilitating these discussions. (We’ve written extensively about the Choosing Wisely campaign.)

“Time really becomes a problem when you talk about addressing this issue. It takes time for a doctor to explain to somebody why the test they want isn’t necessary, and in a clinical setting today you’re almost always running behind.”

“This is where Choosing Wisely is helpful because it can do the education component that’s hard to do in the clinic,” she said. “It’s easy to say, ‘You just need to take the time to answer the patient’s questions,’ but that’s not the reality that we live in.”