COMMENTARY

In Defense of Less-Is-More

John Mandrola, MD

Disclosures

January 09, 2018

As 2017 ended, the influential writer and cardiologist Lisa Rosenbaum challenged the tenets of the less-is-more movement in the New England Journal of Medicine.[1]

Incitement began in the title, The Less-Is-More Crusade—Are We Overmedicalizing or Oversimplifying? Rosenbaum concluded that "Mitigating waste is imperative," but she argued that doing so means considering the nuances of complex medical decisions and that what may be perceived as a greed for dollars may reflect a hunger for information.

I live and breathe less-is-more thinking. To simplify care, to master the obvious, to heal and comfort with fewer drugs and procedures, this, I believe, defines elegance in medicine. Rosenbaum's essay struck at some of my core beliefs. It defended the status quo of American healthcare.

Rosenbaum is a gifted writer; her points are well researched. She has built a reputation for taking tough stances, most remarkably with her three-part series supporting the benefits of physician-industry collaboration.[2,3,4]

This article may be even bolder given that the United States spends far more on healthcare than any other industrialized country and gets no better outcomes.[5] Here she confronts those (like me) who believe medical waste is easily defined, due mostly to greed, and fixable with few tradeoffs. 

Rosenbaum and I are friends, but I will respectfully disagree with nearly every one of her points.

Medical Waste Is Massive

She begins by questioning Dartmouth-based research[6] that claims that up to 30% of health care dollars are wasted. She cites multiple analyses, which note flaws in the researchers' methods; an economic paper that found hospitals with higher treatment intensity had lower mortality rates; and an observational study associating lower rates of admission from the emergency department (ED) with higher mortality.[7,8,9,10,11]

I laud critical appraisal and admit to not knowing exactly how much care is unnecessary. But anyone who practices in the US system knows there is massive amounts of waste. A recent Kaiser Health News piece chronicled widespread cancer screening in elderly nursing home patients. Walk by most nuclear medicine departments and you will see elders in diapers getting myocardial perfusion scans. Then there are the intensive care units, where far too often, we provide wasteful inhumane "care" at the end of life.

I could go on: statins in 90-year-olds with cancer, yearly echocardiograms for mild valve disease, "palliative" chemotherapy, MRIs for low-back pain, arthroscopy, vertebroplasty, etc. Appropriateness criteria are a joke: fleeting noncardiac pain can become precordial pain, thereby justifying swaths of "appropriate" testing and therapy. Electronic health records have made justifying (lucrative) nonsense even easier.

Waste in the US healthcare system need not be precisely quantified. It's like a low left ventricular ejection fraction in a patient with heart failure. It doesn't matter if the ejection fraction is 12%, 15%, or 20%. It's bad. Waste in our system is bad. Debating Dartmouth research merely distracts from the obvious.

Of course some medical decisions are nuanced. Rosenbaum connects the challenges and uncertainties faced by ED clinicians as a possible driver of excess testing and costs. I don't dispute that ED decisions are tough, but the costs of testing and treating vexing cases is hardly the main driver of medical waste in US healthcare.

Clinicians in medical systems all over the globe face tough calls—but other systems spend far less. Costs from tough decisions lie in the tails of the bell curve. The real waste in our system is in the center of the curve. It's in the mundane everyday overuse embedded in our (patients' and clinicians' alike) optimistic notion that more healthcare delivers more health.

Financial Conflicts Are THE Issue

Another point I disagree with is the contention that dollars may not be a major driver of waste. Rosenbaum argues that one's clinical skills could be a factor. High-producing specialists may be that way because of their skill—the experts do more because they are in demand. The less skilled clinicians may be high spenders because of their uncertainty—they overcompensate by ordering more tests.

She deftly bolsters the money-isn't-everything thesis with fear, arguing that we don't know how to safely reduce waste. Trying to change high-spenders into low-spenders risks missed diagnoses and sins of omission. Nothing clears the way for overuse better than fear.

I agree that human nature is complex and money isn't the only driver of waste. But to underemphasize the role of financial incentives is to miss the obvious.

It begins in medical training. Many medical educators do academic research. This means they are aligned with industry, professional societies, and medical journals. (Few contrarians advance in the academic world.) Medical learners, therefore, are immersed in an environment optimistic about the latest drug, device, or surgery. You can't train proceduralists and surgeons unless you do procedures and surgery.

If your mentor is an innovator, it's hard to ask: Hey, are you sure this new thing you love so much is really helping people?

This ingrained culture of optimism serves the medical learner well when he or she hits the fee-for-service system. If doing more pays more, human nature dictates that doctors will do more.

This claim hardly needs a reference, but in case you want one, here is an analysis outlining the relationship between reimbursement and rates of cardiac procedures in Germany.[12] In Germany, cardiac procedures pay well, so it's no surprise that over the past 20 years, the per-capita number of cardiac procedures far outstrips the corresponding figures in other European countries, including those with similar healthcare standards.

Low-Value Care Is Not That Complicated

Citing Daniel Kahneman's work,[13] which observed that humans find it easier to construct coherent stories when there are fewer pieces to fit into the puzzle, Rosenbaum likens criticisms of percutaneous coronary intervention (PCI) for patients with stable coronary artery disease (CAD) to oversimplification.

Her choice to use this example was strange because if one uses the many pieces of evidence (not the anecdotes or beliefs), it's hard to find any benefit from PCI in patients with stable CAD.

My hospital recently had an exemplary case. An interventionalist found a high-grade lesion in a large coronary vessel in a man with no symptoms who was not on medical therapy. His decision not to place a stent unnerved both the referring doctor and the patient. The referring doctor then ordered a nuclear stress test. Not surprisingly, it showed (asymptomatic) ischemia at moderate work loads. The referring doctor and patient now wanted the stent because the stress test was positive.

Ischemia-driven testing like this is endemic. It is the engine that drives cardiology offices and hospitals. But it's often wrong. The highest-level medical evidence finds that PCI in addition to optimal medical therapy does not reduce the chance of myocardial infarction or death.[14] And now, with the recently published ORBITA trial, even angina relief from PCI is dubious.[15]

Given the evidence, the onus is not on the critics of PCI but rather on the proponents to explain why millions of patients have received PCI outside the setting of acute coronary syndrome.

Rosenbaum argues that low-value care can be illusory and mean different things to different people. This is true, but it's no basis for widespread use of low-value care. Letting an elder stay in the hospital an extra day or doing a few more CT chest angiograms or colonoscopies in symptomatic people pales in comparison to everyday waste.

Consider the costs and moral outrage from overmedicalizing antsy children with attention-deficit/hyperactivity disorder drugs, keeping frail elders alive in ventilator hospitals, and scaring people into cancer screening without shared decision making. These are the just three of the shameful realities of US healthcare that we less-is-more crusaders fight against.

Not All Bias Is the Same

I also disagree with Rosenbaum's equating of biases. She writes that industry bias is transparent and well known but is concerned that the public may be less familiar with and less able to weigh "the bias introduced by the less-is-more mind-set." 

Of course all humans have biases, but I don't think they are equal. Profit-driven hospitals, cancer centers, journals, and industry need to sell their wares. What exactly are less-is-more advocates selling?

How does a clinician who publicly argues against a $14,000-per-year drug that provides no mortality reduction garner any benefit? Less-is-more advocates tried for decades to quell antibiotic overuse. Real traction has come only after great harm to patients. What exactly were the biases of the antibiotic stewards?

Rosenbaum is rightly concerned about the declining trust in medical science. I often see patients with minutes (literally) of atrial fibrillation (AF) or nonsymptomatic AF strong-armed into ablation. This is outrageous, a blemish on our profession, and such everyday overuse undermines public trust. 

In my experience, openness about uncertainty and humility only increases trust. But here is the dilemma: Educating patients, improving decision quality, and building trust may mean patients are less inclined to choose the therapies we like.[16]

Conclusion

I believe there is a correct side of the medical waste/overuse argument. I want to be on that side.

The foundation of sound medical care, listening to patients, sharing decisions, and reading the literature critically are inexpensive, just, and likely to deliver improved outcomes. More and more, these basics need an advocate.

I will continue to be a proud less-is-more crusader—being against waste and overuse is not to be an enemy of nuance or innovation.

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