Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz

In the old US television show Let’s Make a Deal the host, Monty Hall, awarded contestants a modest prize but then offered them a gamble: stick with that prize or exchange it for whatever was hidden behind a curtain. It might be a brand new car, but it could be a goat.

In her recent article, “The Less-Is-More Crusade—Are We Overmedicalizing or Oversimplifying?”1, the New England Journal of Medicine’s national correspondent, Lisa Rosenbaum, writes as if she were a risk averse contestant. Despite acknowledging that unnecessary tests and treatments in healthcare cause waste, she wants us to stick with the status quo—afraid that a goat lurks behind the curtain.

Rosenbaum’s article suggests that we don’t know how to eliminate wasteful care without inadvertently reducing beneficial care. And she criticises professionals concerned about reducing overuse as offering an oversimplified promise of “solutions without trade-offs.” But these assertions ignore a large and growing international body of research documenting that the status quo is itself sometimes a goat: patients get both too much and too little care, they have tests and treatments that provide more harm than benefit, and resources continue to be wasted on useless care such as preoperative testing for low risk surgery. It also overlooks the existence of evidence based approaches—not blind guesses—to mitigate overdiagnosis, overtreatment, and waste. To be deliberately provocative, Rosenbaum employs anecdote, selective examples, and caricature to dismiss a difficult but genuine science and to impugn the motives of, as she puts it, “less-is-more crusaders.”

Nevertheless, we should pause for thought. “Less is more” is much easier for policy …