COMMENTARY

Have We Missed the Hidden Cause of Medical Overuse?

John Mandrola, MD

Disclosures

January 28, 2019

Annual physical exams, nuclear stress tests for low-risk chest pain, echocardiography for benign palpitations—the list of low-value wasteful medical care is long.

Professional societies sanction wasteful practices by publishing ridiculously broad appropriate use criteria.[1] Government payers reward its beneficiaries with free low-value care, such as the "welcome to Medicare" exam. Patients have learned to expect low-value care.

These are the norms of US healthcare.

In my struggle to understand overuse, I have considered the obvious: financial conflict of interests of clinicians and hospitals, cognitive bias toward action rather than watchful waiting, and ignorance (willful or otherwise) of medical evidence.

The Elephant in the Brain

Perhaps I have overlooked the elephant in the room, or, as Kevin Simler and Robin Hanson write in their terrific book, The Elephant in the Brain .[2] Simler, a computer scientist, and Hanson, an economist and social scientist, propose that hidden motives may be driving the desire to consume and deliver more medicine than is necessary to achieve health.

Be ready; their core idea may make you squirm. It is that humans are "not only capable of acting on hidden motives—we're designed to do it. Our brains are built to act in our self-interest while at the same time trying hard not to appear selfish in front of other people." This concept provokes because few people eagerly admit that something outwardly kind, such as bringing food to a sick person, may have selfish motives. But the elephant is more than just selfishness; it is a whole cluster of concepts rooted in the fact that we are social animals competing for power, status, and mates.

"Human behavior," they write, "is rarely what it seems." While many thinkers have made this point, the novelty of Simler and Hansen's elephant is that they apply this to large-scale social issues.

Some examples of hidden motives and signaling:

  • In education, we say we are going to college to learn, but really, we go to get a certificate to show off our intelligence;

  • In art, we say we appreciate beauty, but really, we use art to signal our cultivated elite status;

  • In charity, we say we give to help people; instead, we use charitable giving to raise our social status and signal our value as an ally.

The stated reason people seek or deliver medical care is for health. But then four observations by Simler and Hanson suggest a puzzle:

  • In the famous Rand Health Insurance study, people given free healthcare consumed more of it but did not get better health;[3]

  • There exists a general apathy toward nonmedical interventions, like exercise and watchful waiting;

  • Few people show interest in second opinions or outcome statistics; and

  • People readily accept exorbitant and futile care at the end of life.

The authors invoke the story of a mother who kisses the scrape of a toddler: "No healing takes place, yet both parties appreciate the ritual." The ritual shows how we might be programmed to both seek and offer healthcare even when it isn't medically useful.

Conspicuous Caring

The provocative conclusion is that healthcare isn't just about health; it's also a grand signaling exercise called conspicuous caring. If healthcare was only a transaction about getting well, you would expect patients to pay for (and doctors to prescribe) only treatments in which benefits exceed costs. Conspicuous caring provides an alternate explanation for  demand that leads to consumption that exceeds the point of value. And in modern medicine, demand resulting from conspicuous caring can be masked by the real healing that often occurs.

The authors' discussion of the origins of why people want so much healthcare makes sense.

First is the evolutionary argument: Imagine a forager fell ill. Conspicuous caring is important here because rivals are less likely to attack a sick person if he has obvious allies. In the modern world, conspicuously supporting people who are sick signals your value as an ally and raises one's social status.

A historical view of medicine also helps explain the conspicuous caring thesis. Since Medieval therapeutics had few benefits, a show of conspicuous effort was important. Simler and Hanson's story of the medical therapy endured by King Charles II reads like torture, not medical care. Their point is that if the king's doctors prescribed soup and bed rest, people would have questioned whether enough had been done.

Maybe you are thinking: This is cynical—medicine today is so much better. We help people. And yes, that is true, but what Simler and Hanson address is how signaling promotes excess or marginal care that provides no benefit.

They bolster their thesis with three predictions that align with a conspicuous caring motive:

The first prediction is that people prefer treatments that require visible effort and sacrifice.  If medicine were a private transaction for health, it should not matter how elaborate the care is. But then why are patients often dismissive of simple cheap remedies like stress reduction, better diet, and more exercise? Instead, people are drawn to expensive, showy gadgets provided by the city's "top docs." (Think robotic surgery.) And nowhere is the signal of conspicuous caring better illustrated than in end-of-life care. While providing comfort care should put out a strong caring signal, the norm in our death-denial culture is that caring means providing and encouraging aggressive care—however futile.

The second prediction from conspicuous caring comes in society's focus on public rather than private signs of medical quality. In a simple transaction, you care only if your purchase provides value. But when signals are important, people become more interested in the show. This fits with how we focus more on visible credentials and reputations than local performance data.

Simler and Hansen cite a trial showing that advanced care practitioners provide equally good care[4] but people mostly prefer doctor-led care. They also cite another study showing that only 8% of patients about to have risky surgery were willing to spend $50 to learn of death rates from hospitals and surgeons in the area.[5]

Third, conspicuous caring motives also predict our general reluctance to openly question medical quality. To the degree that healthcare functions as a gift (decreasingly so), the norms are to avoid questioning its quality. The signaling notion suggests that it's the thought and effort that count. This well explains the social taboo of skeptical views of medical care, the apathy toward medical errors, and the reluctance to seek second opinions.

Conclusion 

The Elephant in the Brain should come with a warning. Read it and you will see conspicuous caring everywhere.

Cardiac imaging in the millions of people with low-risk symptoms is marginal care that adds little to nothing to health. Yet all parties—patient, family, payers, hospital, and clinicians—accept it. Why? Conspicuous caring is the norm, even in non–fee-for-service systems.[6,7]

The elder who fails to "fight" cancer by rejecting aggressive care breaks a norm. So does the doctor who often sees atrial fibrillation (AF) as a symptom of lifestyle disease rather than an ablatable condition. Due to its risk and invasive nature, AF ablation puts out a strong signal of conspicuous caring.

Simler and Hanson deserve credit for bringing this to light. Exposing our less-then-noble side won't make them stars at dinner parties or earn them faculty invitations at academic meetings.

But this is important stuff. Marginal wasteful care is immoral. I see patients in an underserved clinic who suffer the ravages of preventable disease and can't get basic medical care. Wasting resources on medical overuse worsens these inequities.

Looking inward at these hidden motives may cause us to reconsider choices on what to subsidize.

Here is a dare before entering that order into the electronic health record: Is that test or treatment beneficial? Or is it just a show of conspicuous caring?

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