The Pitfalls of Overtreatment: Why More Care is not Necessarily Beneficial

Abstract

Overtreatment refers to interventions that do not benefit the patient, or where the risk of harm from the intervention is likely to outweigh any benefit the patient will receive. It can account for up to 30% of health care costs, and is increasingly recognised as a widespread problem across nations and within clinical and scientific communities. There are a number of inter-related factors that drive overtreatment including the expanding definition of diseases, advertising and the influence of the pharmaceutical industry, how doctors are trained and remunerated, demands from patients (and their families) and the fear of complaints leading doctors to practise defensively.

This paper discusses a number of ethical and practical issues arising from overtreatment that doctors and patients should be aware of. It also considers the flow-on effects of overtreatment such as the increased cost of care, increase in work load for health professionals, and wastage as resources are diverted from more genuine and pressing needs. In addition, there are references to a number of Medical Council of New Zealand statements about what good medical practice means in an environment of resource limitation. The paper concludes with a few measures that doctors and patients could take to reduce overtreatment but acknowledges that health care is extremely complex so it would be unrealistic to eliminate overtreatment entirely.

Introduction

This paper discusses overtreatment in the context of New Zealand. It references a number of statements by the Medical Council of New Zealand (MCNZ) about what good medical practice means in an environment of resource limitation. Along with registering doctors in New Zealand, MCNZ sets standards for the way doctors practise. Essentially, MCNZ’s mandate is to protect the public who have the right to expect high standards of care from their doctor. Doctors, patients and members of the public often contact MCNZ about its standards and how they apply to a particular situation, such as overtreatment. This paper suggests a few measures that could be taken to reduce overtreatment but acknowledges that health care is extremely complex so it would be unrealistic to eliminate overtreatment entirely.

What is Overtreatment?

Before discussing what drives overtreatment, it would be helpful to understand what overtreatment is. Overtreatment refers to interventions that do not benefit the patient, or where the risk of harm from the intervention is likely to outweigh any benefit the patient will receive (Katz, Grady, and Redberg 2013; Rogers 2014). Related concepts include “overuse” (to refer to services that are unnecessary), “overtesting” (to indicate excessive delivery or provision of investigations) and “overdiagnosis” (the labelling of symptoms or abnormalities that are indolent, non-progressive or regressive which will not affect one’s quality of life or shorten it if the symptom or abnormality is untreated) (Brownlee et al. 2017). A further related concept is medicalisation where non-medical/every day problems are regarded and treated as medical conditions (Hofmann 2016; van Dijk et al. 2016).

Overtreatment is increasingly recognised as a widespread problem across nations and within clinical and scientific communities (Moynihan et al. 2019). A paper by Grimshaw et al. (2020) noted that wasteful care can account for up to 30% of health care costs—a finding that is consistent with a number of international studies. Although overtreatment has mainly been documented in high-income countries, low-and-middle-income countries are not immune. Particularly in low-and-middle-income countries, overtreatment can coexist with unmet health care needs, and result in an uneven distribution of health resources. For example, in India, private health insurance and formal sector employees’ insurance programmes cover expensive cancer drugs for a tenth of the country’s population even though the general population does not have access to many basic health care interventions. Although it is not clear to what extent the use of expensive services represents true overtreatment, costly care affects the viability of public budgets and population health in a country (Moynihan et al. 2014; Brownlee et al. 2017).

Despite a growing awareness that overtreatment is a problem, it is challenging measuring overtreatment because it requires defining what appropriate care is, and quantifying benefits and harms when the evidence for these are often incomplete or poorly documented. In addition, the threshold between appropriate and inappropriate care can vary among patients and patient groups, and it is often unclear whose values and preferences should determine what a benefit or harm is from a treatment or procedure (Brownlee et al. 2017).

To add to the challenge, most doctors seek to be professional, to practise ethically, and to provide an appropriate standard of care (Fuchs 2011). But in seeking to do their best for their patients, doctors may at times overestimate the benefits of an intervention when they carry out or refer their patient for a test, treatment or procedure (Ralston and Schroeder 2015). Because any resulting harms tend to occur downstream (often long after the patient had the test, treatment or procedure), it is usually not apparent at the time an intervention is recommended that it could turn out to be unnecessary. As well, overtreatment tends to be reflected in population statistics and epidemiological studies which are conducted over a period of time. So, most of what is known about the harms from overtreatment is derived from estimates and extrapolations across populations rather than through individual patient encounters (Elmore 2016).

What Drives Overtreatment?

At the heart of overtreatment is a perception and expectation that more care results in a better outcome for the patient even though increasingly, research indicates otherwise (Berwick 2017; Grady and Redberg 2010; Katz et al. 2013; Carpenter et al. 2015). This “more” includes costly care which is often equated with a higher quality of care; use of new(er) technology, devices, equipment and techniques; being prescribed more medication; and being referred for more tests and investigations (Caverly et al. 2014; Hulsbergen et al. 2019).1 Studies show that patients are more satisfied when they undergo more tests and treatment or receive more medication because they perceive that something is being done for their benefit (Moynihan et al. 2012). However, what many patients (and doctors) may not realise is that each test, treatment and procedure no matter how carefully conducted carry a degree of risk including the possibility of error or complications. For example, the more medication a patient is given, the higher the likelihood of a prescribing error, or dispensing the wrong medication, or mixing up and taking the medication incorrectly resulting in an adverse reaction. Similarly, conducting more investigations could lead to false positive results, and undergoing invasive procedures (such as surgery) that the patient did not need (Gupta 2012).

Several factors drive overtreatment and are inter-related. What is discussed below show just how strong and deeply embedded the forces driving overtreatment are within health care and the wider society (Moynihan et al. 2012). To clarify, the intention of this paper is not to cast a negative light on treatment itself but to highlight the tendency to overtreat and the flow-on effects from doing so.

The Expanding Definition of Diseases

Advances in biochemistry and medical technology enable health professionals to investigate more minutely and to detect diseases at earlier stages or at a pre-disease state (Treadwell and McCartney 2016; Heath 2013). This has led to lowering the diagnostic threshold and re-classifying as a disease what was previously considered normal or as part of ageing. Examples include osteoporosis, where treatment may be more harmful than beneficial for those with a low risk of fracture, and behavioural conditions such as female sexual dysfunction where common difficulties such as low libido have been re-classified as dysfunctions (Moynihan et al. 2012; Moynihan 2010).

Another reason why diseases continue to be re-classified is that there are often no agreed standards among panels that review or alter the definition of diseases. Nor are there clear criteria for when it is reasonable to change the definition of a disease, and how conflicts and competing interests should be managed. The changes from DSM-IV (fourth edition of the Diagnostic and Statistical Manual of Mental Disorders) to DSM-5 illustrate the challenges of debating internationally agreed processes (Glasziou et al. 2013). From a commercial perspective, there are advantages in re-classifying and expanding the definition of diseases because more diagnoses translate to more potential for revenue (Lenzer 2012). Related to this, clinical guidelines that recommend how diseases should be treated are often produced by professional associations and people with financial ties to industries who profit from those treatments (Moynihan et al. 2019).

There are flow-on effects from expanding the definition of diseases. It can create the illusion of improved population outcomes in that some who are otherwise healthy are re-grouped as having an illness. Consequently, the aggregate health outcome of those labelled with a particular illness may not seem as severe (Heath 2013). In addition, disease re-classification means that some patients meet the criteria for treatment when they previously might not have under a narrower definition of the disease. That said, it also means living with a label which could affect how a person views themselves, and how others perceive them (Glasziou et al. 2013). This could have wider implications beyond health care such as when a patient applies for a new job or for insurance cover, and has to declare their medical history or is made to undergo a medical assessment. For some, the thought of non-health agencies having access to their health information and using that information to form an opinion about them might seem intrusive, and leave them feeling vulnerable and exposed.

Advertisements

Advertisements are intended to inform and influence behaviour by creating the need for a product or service. However, advertisements that are false, misleading or deceptive can have adverse consequences because patients (and those who are told they are unwell) are generally more vulnerable and inclined to believe claims about treatments and cures, and to seek out those treatments and cures. Others who are also more susceptible to the influence of advertisements include the elderly, ethnic minorities, people with a poorer health status and those in a lower socio-economic group (Chisholm 2019; Lexchin and Menkes 2019).

As part of MCNZ’s mandate to protect public health and safety and to promote good medical practice among doctors, it sets out a number of expectations for doctors who advertise their services. For example, MCNZ’s (2016a) statement on Advertising says that promotional material must contain truthful and balanced representations, and scientific information must be presented in a way that is valid, evidence-based and from a reputable and verifiable source. It prohibits the use of testimonials, and advertisements that glamorise a product or service, or that foster unrealistic expectations. It also cautions against advertising in a way that encourages inappropriate or excessive use of health resources by arousing ill-founded fears about a patient’s health, or that prey on those who are vulnerable. An example of this is advertisements that capitalise on the fear of an undiagnosed disease, and that urge patients to see their doctor for testing (Pathirana et al. 2017).

That said, MCNZ’s jurisdiction is limited to regulating doctors who practise in New Zealand. In other words, MCNZ has no regulatory power in relation to non-doctors and the pharmaceutical industry, meaning they cannot be held to the same standards that are set for doctors. When it comes to promoting and marketing prescription medicines, there is considerable leeway for the pharmaceutical industry as New Zealand permits direct to consumer advertising (DTCA) of prescription medicines. DTCA refers to a form of pharmaceutical industry marketing that targets patients, their families and the wider public by using a variety of media platforms including online advertising, TV, radio, newspapers and magazines.

While proponents argue that DTCA provides information, empowers patients with medical knowledge, encourages dialogue with health professionals and facilitates informed choices about treatment options, these claims are not supported by evidence. For example, a Lancet study found that 87% of direct to consumer advertising described the benefits of a medicine or treatment in vague terms often using emotive language (Woloshin et al. 2001). In the same vein, the minority of DTCA that was supported by evidence tended to present data in ways that were misleading, and that were commonly misinterpreted as trusted public health messages (Schwartz and Woloshin 2019; Lexchin and Menkes 2019). Put simply, DTCA works by promoting messages that increase commercial success (overstating benefits), and omitting messages likely to reduce commercial success (minimising harm). In so doing, DTCA changes the balance of influence on decision-making from persuasion to manipulation, and masquerades as supporting autonomous choice when in reality, it undermines it (Mangin and Toop 2006).

In addition, DTCA leads to unnecessary prescribing in that when patients request a particular medicine, more often than not, they will receive what they asked for even though the prescribing doctor may be uneasy about issuing that prescription (Toop and Richards 2003). Consequently, some patients end up taking medication they do not need or misusing the medications they are prescribed. Overmedication can be harmful in several ways including mixing up different medications and taking medication incorrectly or at a higher dose than prescribed, taking the medication for a longer duration than intended, along with the difficulty in weaning off a particular medication down the line (Best Practice Advocacy Centre 2018). Other downsides of DTCA include the risk of iatrogenic harm because the side effects and efficacy of new drugs are often unknown or unclear; and the increased cost of care because patients tend to opt for costly brands of medicines over cheaper alternatives that could be just as effective (New Zealand Medical Association 2018).

In reality, industry-funded information does not help patients make better decisions but medicalises health by exposing the population to new medicines and treatments with the underlying message that they are beneficial (Toop and Mangin 2007). This is not surprising because strong commercial interests drive the content of what is advertised, and bottom lines, market share, brand loyalty, and finding new target markets influence how pharmaceutical companies promote their products (Toop and Richards 2003).

At present, New Zealand and the USA are the only two countries where DTCA is legal. In New Zealand, DTCA developed because the Medicines Act 1981 did not specifically prohibit the practice, while in the USA, the Food and Drug Administration ruled in 1982 that DTCA did not inherently violate FDA administrative law and regulations (Lexchin and Menkes 2019). That said, New Zealand is in the process of reviewing the Medicines Act 1981 and Medicines Regulations 1984 (the laws that regulate the advertising of medicines in New Zealand). This has led a number of stakeholders to lobby the New Zealand Government to review its position on DTCA (Every-Palmer et al. 2014; Chisholm 2019). There is hope, therefore, that the New Zealand Government will take a stronger stance against DTCA to curb unnecessary prescribing of medicines, and to protect the public from inaccurate claims by the pharmaceutical industry.

The Influence of the Pharmaceutical Industry

Along with advertising its products, the pharmaceutical industry spends billions of dollars to influence health decisions and prescribing behaviours. This occurs in a number of ways including giving doctors and other health professionals gifts and merchandise that market the pharmaceutical company’s products, sponsoring medical education events and conferences, funding doctors to attend overseas conferences (including paying the cost of business class fares), holding dine-and-learn symposiums at expensive venues, and paying eminent doctors and key opinion specialists to speak at conferences, give talks and sit on advisory boards that debate the efficacy and use of a new drug (Macdonald 2014).

Gifts and incentives from the pharmaceutical industry have a subliminal effect in that they create relationships and engender a certain sense of obligation and reciprocation in recipients (Chong 2017). Research indicates that a doctor who interacts with or is sponsored by a pharmaceutical company often reflects a positive bias to that company’s products or services. For example, they are more inclined to prescribe certain medication or to refer the patient for more tests and procedures even if the clinical justification for that medication, test, treatment or procedure may not be strong (Smith 2006). While this is not saying that doctors are susceptible to the influence of marketing all of the time, collectively, a profession that is biased towards certain medications and products will still have a significant effect on what patients are prescribed (Parker 2019; Srivastava 2019). It is this form of bias that doctors are cautioned about in the MCNZ (2012) statement on Doctors and health-related commercial organisations.

Having ties to or interacting with the pharmaceutical industry is not unethical per se. Rather, it is important for doctors to recognise the strong influence that the pharmaceutical industry has, and to carefully manage any inherent conflict of interests that arise from the doctor’s interaction with industry so that patient care is not compromised. It is telling that the pharmaceutical industry is selective about what information they disseminate and who they disseminate that information to. For example, pharmaceutical companies tend to highlight favourable studies from the mass of research conducted, and deliberately omit unfavourable results (Moynihan et al. 2019). By honing in on certain benefits, pharmaceutical companies can lead doctors to believe that their drug or treatment is more effective than it actually is (Chisholm 2019). Because it is time-consuming for doctors to critically evaluate information about different treatments and interventions especially when those treatments or interventions are novel, pharmaceutical companies often fill the gap by having concise and up-to-date information about new treatments. They also compile information on who is more inclined to prescribe their products so that they are more targeted in their marketing efforts (Emmanuel and Fuchs 2008).

The MCNZ statement on Doctors and health-related commercial organisations outlines broadly how doctors should manage conflicts of interests with industry. For example, when presenting at an educational event, doctors are expected to disclose their relationship with the pharmaceutical industry, to provide a balanced view, and to use the medicine’s generic name rather than its trade name. Doctors are also expected to be open and honest with their patients, and with the doctor’s employer and insurer about any conflicts of interests a doctor may have when they prescribe or recommend a certain course of treatment, or if they are involved in the operation, management or governance of a health-related entity. Where that conflict of interest is likely to compromise the patient’s care, doctors are advised to refer the patient to another doctor or to other sources of care. This helps to ensure that the patient’s interests remain at the forefront of the doctor’s clinical decisions.

Of course, the publication of a statement such as Doctors and health-related commercial organisations is no guarantee that doctors will adhere to it. Doing the right thing including acting in the patient’s best interests also comes down to one’s values, character, conviction and professionalism, along with the collective values of the doctor’s workplace. That said, having such a statement gives MCNZ a standard to hold doctors to. It is a reminder to the medical profession in New Zealand that high standards are expected from registered doctors, and that includes acting professionally and ethically in their dealings with patients and with industry.

How Doctors are Trained

Medicine is an action-based profession in that medical students and doctors are taught how to do things, and to fix, solve and resolve problems (Morgan 2020). There is an emphasis on being thorough and on identifying a range of diagnoses and investigations to treat a problem. Generally, if more tests and interventions were initiated, the more thorough and competent the doctor is perceived to be. Such a view can encourage overtreatment. This is not to say that doctors deliberately set out to overtreat but that overtreatment can and does occur in the course of trying to uncover what is wrong with the patient (Lenzer 2012; Emmanuel and Fuchs 2008).

Sometimes, it can be difficult to relinquish ingrained practices in that some tests, treatments and procedures that are not clinically warranted continue to be carried out. For example, X-rays, CT and MRI scans are commonly used to diagnose acute lower back pain even though imaging does not improve pain and function, and there are no clinical reasons to suspect serious spinal pathology. Another example is the use of percutaneous coronary interventions in patients with stable, non-critical coronary artery disease despite the lack of evidence that such an intervention is effective (Scott and Elshaug 2013).

That said, there is increasing emphasis in medical training on not overtreating, along with an awareness of the pitfalls in doing so. For example, the New Zealand Medical Students’ Association (which represents all medical students in New Zealand) has created a list that encourages students and trainees to question whether a test, treatment or procedure is necessary, to explore whether there are less invasive and less resource-intensive alternatives, and to take time to evaluate with the patient whether a test, treatment or procedure is clinically warranted (Choosing Wisely New Zealand 2017). This list is based on Choosing Wisely principles, which will be discussed later in the paper.

How Doctors are Remunerated

Different models of care delivery promote different behaviours, and how doctors are remunerated can influence how they practise and the clinical decisions they make. For example, doctors in private practice usually operate a fee-for-service model where they charge for each consultation conducted, and for each test and procedure performed. Although most doctors do not intentionally abuse or defraud the health system, operating a fee-for-service model essentially means earning more for doing more irrespective of what the outcome may be for the patient (Emmanuel and Fuchs 2008). Because the viability of a fee-for-service model depends on the volume of services provided, it tends to incentivise quantity over quality by encouraging high volumes of care often at the expense of other aspects of high-quality care such as taking the time to listen to and engage with patients (Yoong 2019).

This was illustrated in a 2017 New Yorker article about incremental care. Atul Gawande (an American general surgeon and public health researcher) noted that the five highest paid specialties in American medicine (orthopaedics, cardiology, dermatology, gastroenterology and radiology) were all interventionists where most of the doctor’s income is based on performing one-off procedures. In contrast, the lowest paid specialties (paediatrics, endocrinology, family medicine, infectious disease, immunology, internal medicine, psychiatry and rheumatology) involved incremental care where patients are seen over a period of time (Gawande 2017). Yet compared with one-off interventions, doctors who see their patients over a period of time tend to have a bigger impact on improving health outcomes. This is because knowing the patient (or something about the person they are caring for) makes it easier to discuss information with them including the clinical justification for (not) recommending certain options, and for the doctor to propose a treatment plan that is appropriate and acceptable to the patient. In other words, continuity of relationships facilitates earlier recognition of and attention to clinical problems along with increased patient compliance (Sudhakar-Krishnan and Rudolf 2007). Continuity of care also results in higher patient satisfaction and engagement with the health system (Salisbury 2019).

A related point is that where the patient has private health insurance cover, doctors are often inclined to do more for their patient because they know they will be paid for what they do. Patients in turn have less reservations about undergoing a test, treatment or procedure when they know that their insurer is paying. In other words, when access to care is not an issue and there are no measures in place to evaluate why a patient is seeking more care, there is a tendency to overtreat (Emmanuel and Fuchs 2008). As discussed below, this results in waste and impacts on other patients who may need care more urgently.

Patients or Their Families Expect (and Sometimes Demand) More Care

Advances in medicine and technology continue to delay death by pushing the boundaries of what can be treated and cured. In turn, it is harder for patients and their families to accept that medicine has its limits, and that not every disease or symptom can be treated or cured. As a result, patients and their families might expect or demand that doctors initiate or continue a course of treatment even though that treatment may not be clinically viable for the patient. For example, cardiopulmonary resuscitation (CPR) is rarely a lifesaving procedure for patients with an incurable illness who are expected to die within days or weeks. Even in exceptional cases where CPR does re-establish some cardiac function, it will only extend the patient’s life briefly, and that quality of life is likely to be poor. However, unless patients and their families understand that a successful outcome is unlikely, they may believe erroneously that the patient is being denied a lifesaving procedure (Thorns and Garrard 2011, 69–70).

Related to advances in medicine and technology, the internet is changing the balance of knowledge between doctors and patients (Powell et al. 2003). For example, patients commonly research their symptoms and the different options for treating those symptoms (including less conventional approaches) even before they consult a doctor. This can affect the consultation in that the patient may present with pre-conceived notions and expectations that their doctor should prescribe them with a certain medication and/or refer them for further investigations. In other words, online information can add a new interpretive role to the doctor’s responsibilities since internet-informed patients often come with more questions, are more resourceful and demanding, and tend to request additional treatments and medications during the consultation (Chong 2014; Tan and Goonawardene 2017). Doctors in turn may feel pressured to oblige their patient especially when acceding to their request takes less time and effort compared with discussing with the patient whether a certain medication, test or procedure is actually beneficial for them. This can create tension in the treating relationship especially when what the patient is seeking is not aligned with best practice (Toop and Richards 2003).

In Use of the internet and electronic communication, MCNZ (2016b) takes the view that patients should not be dissuaded from using the internet to research their condition and symptoms but should be mindful that internet research is not a substitute for seeing a doctor. In the same vein, MCNZ advises doctors to discuss with their patients the information they have sourced over the internet, and to explain that sometimes, the quality of that information could be questionable or misleading. In those instances, it encourages doctors to explore with patients their expectations and goals, and to direct the patient to more reliable sources of information. Discussion with the patient is vital, and this is a point that will be revisited later in the paper.

The Discomfort of Uncertainty

Uncertainty is an inherent part of medical practice. Nearly all clinical judgement involves a degree of uncertainty which cannot be eliminated no matter how experienced the doctor. For example, a doctor may have expertise in treating certain conditions or problems but this does not mean that they know for sure whether they have made the right diagnosis for a particular patient, or how that patient will respond to a recommended course of treatment (Hatch 2016, 16). As discussed, it is often difficult to predict which tests or interventions will benefit which patients, and which tests or interventions will turn out to be unnecessary. In addition, certain interventions could be valuable for a small number of patients even though their overall cost is greater than their benefit when that intervention is viewed on a population level (Fuchs 2011).

One example of overdiagnosis directly related to uncertainty is in detecting cancers. By increasing the number of biopsies performed, there is a higher tendency that pathologists will find groups of cells whose overall appearance is odd and suggestive of cancer. While those cells may fit the definition of “cancer” in a strict technical sense, in some instances, they are not harmful if left untreated. That said, ascertaining which patients with cancerous cells are most at risk of dying from the disease itself is not a clear-cut exercise (Hatch 2016, 38–39).

However, uncertainty is often overlooked or downplayed in medicine. Part of that stems from how doctors are trained in that there is a tendency to expect that a treatment or intervention will be beneficial (Campbell 2014). Patients and their families in turn expect their doctor to make the correct diagnosis including recommending the most appropriate course of action, and can be unforgiving when that diagnosis is inaccurate, or if the intervention turns out to be ineffective (Heath 2014).

This highlights the importance of having an honest and open discussion with patients about the basis for recommending a particular course of treatment or procedure especially when there are questions about its efficacy. While discussions in themselves will not eliminate the uncertainty that is inherent in medicine, acknowledging and helping patients see that uncertainty exists can foster more realistic expectations of outcomes and what medicine can (and cannot) do. At the very least, it opens a dialogue and engages the patient.

Fear of Complaints Resulting in Defensive Medicine

Most complaints about a doctor’s care tend to focus on omissions and what a doctor did not do for the patient rather than for overtreating the patient. To reduce the risk of a complaint, some doctors recalibrate their practice by carrying out extra tests and procedures. This is a practice known as defensive medicine. Primarily, the aim of practising defensively is to protect the doctor rather than to encourage best practice (Cunningham and Wilson 2011; Wai 2019). As discussed, not all tests, treatment and procedures improve patient outcomes, but what is certain is that increasing their volume increases the likelihood of medical errors occurring. For example, a 2019 British Medical Journal study found that preventable patient harm affects at least one in 20 patients in a medical care setting, and that harm was mostly related to drug incidents, therapeutic management and invasive clinical procedures (Panagioti et al. 2019).

In line with the principle of non-maleficence, most doctors do not set out to harm their patients deliberately by misdiagnosing them or administering incorrect treatment. But errors are part of being human, and doctors are no exception. Put another way, errors are an inevitable part of medical practice, and some errors can have devastating consequences for the patient (such as permanent disability or death) and for the clinical team involved. Often, errors occur when multiple contributing factors converge, and the common reaction is to identify and blame the individual doctor involved (Kohn et al. 2000, 49). While such a response may be emotionally satisfying for those who have suffered harm and loss, it is ineffective in the long run because it does not bring about any change in the factors that contributed to the error. In addition, blaming the doctor for an unsatisfactory outcome can destroy trust and goodwill in a treating relationship, and erode a doctor’s sense of confidence and clinical judgement (Cunningham and Wilson 2011). Again, this highlights the need for discussion—for doctors to help their patients understand that more treatment does not necessarily lead to a better outcome, and for doctors to be mindful of this before they recommend a test or treatment to a patient even if they are seeking to protect themselves to some extent.

What are the Consequences of Overtreatment?

Each factor discussed in the previous section contributes to some level of unnecessary care. Because they are present to some extent in every health system, collectively, they compound the effect of overtreatment, as many of the factors are inter-related.

There are a number of consequences from overtreatment. By spending time and money on interventions that do not provide any real benefit to the patient, it increases the cost of care making care less affordable and accessible (Treadwell and McCartney 2016). Overtreatment also increases the workload of doctors and other health professionals who spend time seeing patients and reviewing information about them even though they do not need that care. This causes wastage and is contrary to distributive justice which requires doctors to make the best use of available health resources based on need and evidence of benefit (Gillon 1994). Because overtreatment diverts health resources away from other more pressing needs, some patients may miss out on care or miss opportunities for earlier intervention when they have to wait longer before they are treated.

Beyond the individual patient, overtreatment threatens the sustainability of a health system (Moynihan et al. 2019). As health resources are finite, spending more on delivering care could mean that there are less funds available for other areas such as public health, education, housing and social programmes. In turn, failure to prioritise or invest adequately in these areas may mean a poorer outcome for a population because social determinants also impact on health outcomes (Jones and McCullough 2007; Caverly et al. 2014).

To clarify, the aim of reducing overtreatment is not to ration health care. Rather, it is to ensure that each patient receives the right amount of care based on their clinical need. When that happens, health resources can be said to be used optimally (Lenzer 2012). While there is no simple formula to achieve that, there are measures that can be taken to reduce overtreatment.

How can Overtreatment be Reduced?

Given that that health care is extremely complex and there are many components in a health system, tackling overtreatment will require a multi-pronged approach involving different stakeholders across the health system including government, policy makers, health professionals, patients and the public.

For those who make decisions about health care funding, expenditure and resource allocation at higher institutional, systems or governmental level, it is important to acknowledge that such decisions have wide-ranging implications. Along with considering the interests of patients and issues of quality and safety, those in clinical governance roles have a duty to the wider community to promote equity and to encourage the optimal use of resources available which is a point highlighted in MCNZ’s (2018) statement on Safe practice in an environment of resource limitation. Of course, facilitating that is challenging when there are competing interests and priorities, and difficult decisions have to be made about whether certain procedures or treatments are clinically necessary or appropriate. Because such decisions are both funding and clinical decisions, they should (ideally) be guided by evidence from research and audit (Morris 2017).

For those who are not in clinical governance roles, it is still important to recognise that health care resources are limited, and that every clinical decision is also a resource decision which impacts on the care a patient receives, and on others in the wider community. In other words, decisions about treatment and how health resources should be used involve balancing different priorities in that providing one service or intervention may mean not providing another service or intervention, or limiting its volume or scope. In essence, doctors are stewards of health care resources. This means that they have both a professional and ethical obligation to avoid and eliminate wasteful expenditure in health care so that patients can continue to receive the best quality care now and in the future (Medical Council of New Zealand 2018).

As part of good stewardship, there are some measures that individual doctors and patients can take to tackle overtreatment. While these measures will not eliminate overtreatment entirely, they are small steps towards that goal.

The Importance of Discussions between Doctors and Patients

Trust is a key part of the doctor-patient relationship and lies at the very heart of medical practice. That trust lets a patient share and discuss private, confidential and personal information with their doctor from which their doctor considers how a problem should be managed. Ideally, discussions about treatment options should not be limited to clinical risks and benefits but should include finding out what matters to the patient, and what their values, goals and circumstances are. Patients often want more information than they are given so along with answering the doctor’s questions, patients should also be given the opportunity to ask questions that are important to them (Gask and Usherwood 2002; Chatburn 2019). While patients might not always know what is best for them clinically, they are often clear about what they do not want and what they are not prepared to take on even if they do meet the criteria for treatment (Myint 2019).

MCNZ’s (2019) statement on Informed Consent: helping patients make informed decisions about their care encourages a shared decision-making approach where the doctor and patient work together on how the patient’s care should be managed. Sometimes, this may entail seeking input from other doctors and health practitioners as well as those the patient has a close relationship with such as their family. The goal is to devise an appropriate care plan that works for the patient and is in the patient’s best interests.

Of course, time spent in conversations with patients might seem counter-intuitive and time-consuming as it adds to the heavy workload that many doctors and health professionals contend with. However, health care by definition is delivered in the context of relationships, and relationships are formed and sustained by communication (Maskrey 2019). So, talking to patients and knowing something about them as a person are effective ways to build trust. Conversations are also a platform for doctors and the clinical team to address the patient’s concerns, and to recommend treatment options that are appropriate and acceptable to them. At times, that option could include not treating at all or monitoring the condition for a period of time before deciding whether to treat. Conversely, doctors who do not know their patients are more inclined to rely on tests, investigations and referrals to answer clinical questions. Doing so could exacerbate the problem of overtreatment, and increase the doctor’s workload and that of other clinicians (Sirovich et al. 2011).

The Need for Humility on the Part of Doctors

As highlighted earlier on, uncertainty is a reality in health care. It is precisely because doctors do not know with absolute certainty which patients will respond well to a procedure or treatment that they should avoid providing the kind of (over)confident predictions that are often expected of them by patients and their families or that they may expect of themselves.

This calls for humility. Humility involves saying words such as “I do not know” or “I am not sure” without moving immediately into a defensive stance. Admitting that doctors do not and cannot know everything is an approach that many doctors find hard to embrace when talking to patients but there is considerable wisdom in acknowledging the limits of one’s understanding (Morgan 2019). It encourages a greater level of listening and input from the patient and their family which is especially important when managing chronic and life-limiting conditions. To do this, doctors need to ask questions and to engage and build a rapport with their patients. As mentioned earlier, it involves finding out what the patient’s concerns, goals and values are along with ascertaining what they understand about their illness because medical diagnoses and treatments are not distinct and isolated from the psychological and social context in which the patient operates (Cook 2017). It is also important to assess honestly the different risks that are relevant to the patient so that the patient can make an informed decision about how they should proceed. Because many patients implicitly trust their doctor, being honest and open with patients empowers them, and fosters a sense of confidence in the treating relationship (Hatch 2017). In turn, that trust leads to a greater willingness on the part of patients to engage, and to adhere to advice resulting in better outcomes (Gawande 2017).

Helpful Questions to Ask before Going Ahead with Treatment

Globally, different campaigns have been launched to raise awareness of and to tackle the problem of overtreatment. One such campaign is Choosing Wisely which was first devised by the American Board of Internal Medicine Foundation in 2012. Since then, Choosing Wisely has been implemented in a number of countries including Australia, Brazil, Canada, France, Germany, Israel, the UK, Saudi Arabia and New Zealand. The campaign aims to promote a culture where low value and inappropriate clinical interventions are avoided, and patients and health professionals have well-informed conversations around their treatment options, leading to better decisions and outcomes (Sherwood et al. 2017).

To help patients receive the right level of care, Choosing Wisely recommends that patients ask four questions of their doctor or health professional:

1. Do I really need this test or procedure?

This question aims to help patients understand their doctor’s rationale for recommending a test or investigation so that the patient can weigh up the benefits and risks of undergoing that test or treatment.

• 2.What are the risks of having the test or procedure?

Patients are encouraged to discuss with their doctor or health professional what is likely to happen if they have or do not have that test or procedure, along with potential side effects, the chances of getting inaccurate results and the need for more testing or other procedures.

• 3.Are there simpler, safer options?

Sometimes, making lifestyle changes may be more effective than prescribing a medicine for a condition. In addition, patients are encouraged to explore with their doctor or health professional whether an alternative test or treatment might provide useful information, and reduce any potential negative impact for the patient.

• 4.What happens if I do not do anything?

This question is aimed at helping doctors and patients recognise that at times, it might be viable not to treat, or not to treat immediately but to monitor the condition over time, and to make a decision at a later date. Put another way, this question provides the opportunity to pause and reflect by not rushing into a course of treatment.

Despite the growing number of countries that have embraced Choosing Wisely, there have also been criticisms that Choosing Wisely relies on medical and specialist societies to identify tests, medications, treatments and procedures that have been used inappropriately. That in turn could mean focusing disproportionately on that specialty’s procedures and approach to treatment rather than taking a big picture approach on overtreatment (Casarett 2016). Another criticism is that a campaign alone is insufficient to curb the problem of overtreatment which as discussed earlier requires a multi-pronged approach.

It is beyond the scope of this paper to evaluate the merits and limitations of a campaign such as Choosing Wisely. Suffice to say, it is important to start somewhere, and a campaign that encourages patients and health practitioners to engage in conversation about treatment options including asking the four questions listed is one way forward.

Conclusion

Overtreatment is a pervasive problem worldwide. It causes waste as it diverts health resources from those who need it more. In addition, patients are at a greater risk of harm when they undergo tests and procedures they do not need. Along with the increased likelihood of medical errors, spending time and resources on low-value care also increases the cost of care, which can threaten the sustainability of a health system, and make care less affordable and accessible.

Because overtreatment is driven by a number of inter-related factors, tackling it requires a concerted effort and a multi-pronged approach by different stakeholders in the health system. While it would be unrealistic to eliminate overtreatment entirely, there are steps that doctors and patients can take towards that goal. They include discussing what matters to the patient so that the doctor is better placed to recommend treatment options that align with the patient’s goals and values. As well, pointing out the risks and uncertainties inherent in treatment and giving patients the opportunity to ask questions that are important to them help patients make a more informed decision about how they should proceed.

If nothing else, such conversations highlight the reality that more care may not necessarily result in a better outcome. Being aware of that fosters more realistic expectations about treatment, and a clearer understanding of the patient’s condition and prognosis. If more doctors and patients engaged in honest and open conversations, that would have far-reaching benefits for any health system.

Compliance with Ethical Standards

Conflict of Interest

I have been a Senior Policy Adviser and Researcher with the Medical Council of New Zealand (MCNZ) since December 2014. MCNZ is responsible for registering doctors who practise in New Zealand, and setting standards for the way our doctors practise. A large part of my role involves researching and writing those standards which are used to assess a doctor’s conduct and competence. I am often contacted by doctors, patients and members of the public about our standards and how they apply to a particular situation. I also facilitate consumer panel discussions about our standards so that the needs and perspectives of consumers are reflected in the standards we set. In addition, I am part of MCNZ’s Triage Team that makes initial decisions on how complaints about doctors should be handled.

I researched and wrote the following MCNZ statements mentioned in my paper:

• Advertising

• Safe practice in an environment of resource limitation

• Informed consent: helping patients make informed decisions about their care.

MCNZ endorses Choosing Wisely’s campaign, and a number of its principles are reflected in our statements including Safe practice in an environment of resource limitation, and Informed consent: helping patients make informed decisions about their care.

I was a member of the Editorial Board of Cole’s medical practice in New Zealand when it was updated in 2017. (Cole’s is a handbook published by MCNZ for new doctors and doctors new to medical practice in New Zealand.)

While my paper references two chapters from Cole’s and a number of MCNZ statements, the views expressed in my paper are my own, and are not to be attributed to MCNZ.