Selling Sickness 2013

just say, “hold on a minute!”

The Choosing Wisely project, begun only in 2011, is really picking up speed. Dozens of medical specialty organizations have now contributed their lists of five interventions that should be questioned (e.g., do you really need pre-procedure medical tests before eye surgery?, do you really need additional CT scans when the results won’t change treatment planning?,  do you really need repeated MRIs to assess arthritis?, do you really need a routine health exam if you are asymptomatic?). These are from the ophthalmology, gastroenterology, rheumatology, and internal medicine lists, and there are so many fascinating others.

In the face of this important trend, more authors are examining the reasons behind overtreatment. A recent paper by Philadelphia physicians Andrew Foy and Edward Filippone presents the case for a pervasive “Intervention Bias” in medicine that is composed of:

  • Publication Bias (journals favor positive results of drugs and treatments)
  • Self-Interest Bias (financial benefits result from interventions)
  • Confirmation Bias (preferential reliance on who and what one already believes)
  • Fear of malpractice suits (defensive medicine)
  • Patients’ insistence on getting all the tests and screens covered by their insurance

The therapist and social scientist in me (L.T.) especially appreciates the power of the “confirmation bias,” as explored by social psychologists Carol Tavris and Elliot Aronson in their masterful Mistakes Were Made (But Not by Me): Why We Justify Foolish Beliefs, Bad Decisions, and Hurtful Acts. Self-justification is the name of the game in much of adult life, as we all make choices that support our self-esteem (“I am recommending this test/treatment because it is medically necessary not because I am a sheep/coward/uninformed professional”). Tavris and Aronson explain the theory behind self-justification with a blizzard of research and compelling examples.

As one Amazon reader said, echoing, my experience,

“This book is amazing because as you read it you go through three distinct stages of understanding.

Stage 1 (50 pages in)

You say to yourself: “Wow, I know quite a few people who are making the mistakes described in this book.”

Stage 2 (halfway through)

You say to yourself: “Wow, EVERY single person I know is making the mistakes described in this book.”

Stage 3 (by the time you finish the book)

You say to yourself: “Wow, I myself have been making the mistakes described in this book, and I didn’t even realize it.”

I think we can eliminate publication bias, financial conflicts of interest, wrong-headed insurance politices, and maybe even fear of malpactice (which, as Foy and Filippone point out, is a fear more in the mind than reality), but until people and professionals learn to challenge their own rationalizations, we will need reform movements like Choosing Wisely to help us resist the temptations of overtreatment.

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