Re: Overcoming overuse: the way forward is not standing still—an essay by Steven Woloshin and Lisa M Schwartz
Woloshin and Schwartz, alongside other Less Is More Crusaders, place great faith in sharing decisions as a way forward in the fight against overdiagnosis.(1) I consider myself a Less Is More Crusader, but I am slightly less optimistic about the potential of shared decision making to fix this complex problem. The process of providing unbiased information about benefits and harms and aligning health decisions with preferences and values, is clearly preferable in some clinical contexts. The decision to undergo breast cancer screening, for example, where women must weigh the likelihood of avoiding early death with the likelihood of overdiagnosis, lends itself to shared decision-making and the philosophy of informed choice. In other clinical contexts, where the benefit/harm trade-off clearly indicates net harm, this approach may be less valuable. Imaging of non-serious low back pain, for example, is a test that offers patients no benefits but substantial harms from overdiagnosis and overtreatment.(2) It is discouraged by all clinical guidelines. Should clinicians be spending time sharing decisions about having this test or should it be off the table altogether? While I agree with Dr Duddy in her response—we should continue investigating key drivers of overtesting and overtreatment—this will be slow. We need action now. A promising way forward would be to conduct more high-quality trials of strategies to stop clinicians providing tests that are clearly useless and harmful.
Woloshin and Schwartz also raise an important ethical conundrum for those charged with preventing overdiagnosis. The authors state emphatically: “Hype is hype, whether for more or for less care.” In other words, any use of hype or exaggeration of findings—rather than providing balanced information—to promote one’s agenda, never leads to good things. I disagree with this conclusion. My question to the authors is: if our goal is to change behaviour (e.g. encourage conversations between patients and doctors about harms of overtesting, discourage clinicians ordering tests by default etc.) how might we do this without some hype, persuasion, or at least a nudge, in the ‘right’ direction?(3) The authors acknowledge that the numbers are usually uncertain. Will it be enough to—taking the informed choice/shared understanding approach—inform the public of the magnitude of benefit (which we are uncertain about) and compare it to the magnitude harms from overdiagnosis (which we are uncertain about)? It is also worth noting that the Less is More movement is the underdog here; up against a culture where deep-seated beliefs that more-is-better dominate in healthcare and in popular media, and where powerful companies and individuals profit substantially from providing more rather than less.(4) Is it unethical, then, to use hype, persuasion, or hyperbole to level the playing field, especially if that hype could ultimately improve health? One of the recommended strategies to tackle cultural drivers of overuse is a public awareness campaign.(4) Should designers of these campaigns draw the line at promoting informed choice? Or should they consider approaches that can change behaviour and reduce harm, but that risk undermining public trust?
1. Woloshin S, Schwartz LM. Overcoming overuse: the way forward is not standing still-an essay by Steven Woloshin and Lisa M Schwartz. BMJ. 2018;361:k2035.
2. Hartvigsen J, Hancock MJ, Kongsted A, et al. What low back pain is and why we need to pay attention. Lancet. 2018. doi: 10.1016/S0140-6736(18)30480-X. [Epub ahead of print]
3. Scott IA, Soon J, Elshaug AG, Lindner R. Countering cognitive biases in minimising low value care. Med J Aust. 2017;206(9):407-11.
4. Pathirana T, Clark J, Moynihan R. Mapping the drivers of overdiagnosis to potential solutions. BMJ. 2017;358:j3879.
Competing interests: No competing interests