Overuse of health care refers to tests, treatments, and even health care settings when used in circumstances where they are unlikely to help. Overuse is not only wasteful, it threatens patient safety by exposing patients to a greater chance of harm than benefit. It is a widespread problem and has proved resistant to change. Overuse of diagnostic testing is a particular problem in emergency medicine. Emergency physicians cite fear of missing a diagnosis, fear of law suits, and perceived patient expectations as key contributors. However, physicians’ assumptions about what patients expect are often wrong, and overlook two of patients’ most consistently voiced priorities: communication and empathy. Evidence indicates that patients who are more fully informed and engaged in their care often opt for less aggressive approaches. Shared decision making refers to (1) providing balanced information so that patients understand their options and the trade-offs involved, (2) encouraging them to voice their preferences and values, and (3) engaging them—to the extent appropriate or desired—in decision making. By adopting this approach to discretionary decision making, physicians are better positioned to address patients’ concerns without the use of tests and treatments patients neither need nor value.
Overuse of health care occurs on a wide scale and presents a threat to patient safety. Overuse of diagnostic testing in particular is a problem in emergency medicine. Fear of missing a diagnosis, fear of law suits, and perceived patient expectations are among the explanations most frequently cited by emergency physicians.
Shared decision making–informing and engaging patients, and eliciting their preferences for care–is an underutilized resource for tailoring medical care to the individual patient. Evidence indicates that patients who engage in it often opt for less aggressive approaches to care. Shared decision making has the potential to reduce the delivery of care that may be neither beneficial to, nor desired by, patients.
A significant portion of the medical care patients receive is of little or no benefit, or is as likely to harm as help. According to a 2012 Institute of Medicine report, unnecessary services, commonly referred to as overuse, comprise the single largest source of waste in US health care—waste accounting for as much as 30 percent of all health care spending [
Addressing overuse has been identified as a national priority for US health care reform [
Overuse takes different forms in different specialties. Unnecessary invasive procedures predominate in some; medications and screening tests in others. In EM, overuse of diagnostic testing is the problem [
Much of the evidence of CT overuse comes from observations that, despite steep increases in CT use for a variety of indications such as trauma-related conditions, pulmonary embolus, and respiratory infections, no corresponding improvement in clinically important disease detection has been seen [
Additional examples of overtesting and its consequences in EM include the routine initiation of, or referral for, cardiac work-ups for low or very low-risk chest pain patients, which increase cardiac catheterization and revascularization rates without improving outcomes [
Research dating back to the 1970s lent valuable insights into overuse. Epidemiologist and physician John Wennberg and a colleague, tracking health care delivery patterns in Vermont and Maine, made what was at the time a surprising discovery: rates of surgical procedures varied markedly from one part of a state to another—even between neighboring districts [
Subsequent work by Wennberg and the Dartmouth Atlas Project showed that greater health care utilization in a given region mirrors greater concentrations of local health care resources, e.g., specialists, medical technologies and hospital beds—but is associated neither with sicker patients to begin with nor with better outcomes [
Financial incentives, while undoubtedly behind much of the overuse in health care, are only one among many non-clinical pressures acting on physician decision making. In fact, personal financial motive is unlikely to explain most overuse in EM, given that many EPs—particularly those in the academic sector or paid on salary—are entitled at best only to indirect remuneration for individual services provided. A bigger factor, EPs say, is fear. In a 2015 survey by Kanzaria et al. [
Risk-aversion and intolerance for uncertainty are unsurprising, given the context in which EPs function. EM pairs high-stakes decision making with a unique set of challenges. These include lack of time (limiting the opportunity to gather a thorough history, learn potentially relevant psychosocial or other contextual factors, and establish trust), lack of an ongoing relationship between physician and patient, inconsistent access to prior medical records, and uncertain access by patients to appropriate follow-up. There is also a widespread perception among EPs that they face especially high medicolegal risk, but a 2011 Research and Development (RAND) Corporation study indicated only slightly aboveaverage claims rates, average payout rates, and below-average (both mean and median) total payouts [
Additional drivers of overuse cited by EPs in the survey by Kanzaria et al. [
Is change possible under such circumstances? Large-scale reform of health care overuse, most believe, will require systems-level solutions, including alternative payment models that reward quality over volume; national initiatives aimed at promoting evidence-based standards and appropriate-use criteria; administrative-level efforts such as feedback to physicians on test-ordering metrics; and medical education reform. Surveyed EPs say they believe tort reform is needed above all, but studies to date have failed to show a reduction in practice intensity (e.g., imaging rates) in states which have undergone tort reform [
One influence on physicians’ decisions, however, though currently perceived as part of the problem, may have the potential instead to help: patients’ own preferences for care. Physicians are not only duty-bound to place patients’ interests first in making health care decisions, patients have a legal right to information about their health care options, and to weigh in on these – to refuse specific care, for example, or to request one approach over another, where more than one reasonable option exists. Engaging patients in their health care is increasingly seen, too, as an ethical mandate for physicians [
Both elsewhere in medicine and in EM, physicians are frequently swayed by what they perceive their patients’ (or patients’ families’) expectations to be [
But physicians are often mistaken about patient expectations and preferences, even as they try to meet them. EPs treating patients with diarrhea have been found more likely to prescribe antibiotics if they believe patients expect them, but they correctly identify expectations only a third of the time [
Even when physicians are correct about patients’ expectations, they may assign them too much weight: fulfillment of expectations has not been shown to be a consistent or dominant factor in patient satisfaction. A review of 19 studies of visit-specific expectations found only a modest relationship between expectations and satisfaction [
To the extent that meeting patients’ expectations for specific tests or treatments sometimes does predict greater satisfaction, patient satisfaction can be at odds with health outcomes. In a randomized controlled trial of imaging versus no imaging for patients with low back pain, for example, patients in the imaging group were more likely to report pain at 3 months and to have consulted their physician again, yet were ultimately more often satisfied with their care [
The pursuit of patient satisfaction is no guarantee of high-quality care—nor even, where patients’ preferences are inferred and not confirmed, of satisfaction itself. But there is nevertheless much to be learned from what patients say matters to them.
Studies have overwhelmingly found the quality of physician-patient communication to be a top patient priority [
Failure of physicians to deliver on these expectations is not only a common patient complaint, it is among the factors most frequently cited by patients who sue [
Patients often have specific concerns which they may or may not volunteer. Failure of physicians to identify and address these, coupled with the reflexive ordering of tests or treatments, can represent a missed opportunity to reassure through dialogue and education. For example, physicians may assume parents expect antibiotics when instead they may merely be looking for assurances that their child’s illness isn’t serious, or validation of their decision to seek medical care [
Requests for imaging, e.g., among patients with low back pain, may reflect a desire by patients for validation of their suffering [
Additional factors that may contribute to patient requests for unnecessary care include lack of knowledge, direct-to-consumer advertising, moral hazard resulting from third-party payment, and the fear that physicians and health care facilities may ration care to cut costs. Rather than undermine the value of communication and empathy, however, these challenges underscore the importance of addressing patients’ expectations explicitly and forthrightly, providing relevant education, listening, and reassuring. Indeed, evidence exists that brief patient education can increase patient satisfaction when, for example, imaging is not recommended [
Patients frequently hold beliefs about health care that run counter to the evidence [
But patients’ beliefs about health care are at least in part a reflection of their prior experiences with it. Intervention bias on the part of physicians is well documented [
Evidence suggests, however, that when patients are provided with balanced information, they show less inclination to undergo interventions. In considering whether to take medication for cardiovascular disease prevention, for example, older patients have been found to be more sensitive to knowledge of adverse medication effects than to knowledge of benefits [
Taken together, the evidence reviewed above argues for medical decision making that is centered on information exchange and explicitly identifies and addresses the individual patient’s concerns and preferences. This two-way exchange between patient and physician is the essence of shared decision making (SDM).
SDM arose as a concept in the 1980s, propelled by a cultural shift in medicine toward greater patient autonomy and away from paternalism. It is by now widely endorsed. In its 2001 report, “Crossing the quality chasm: a new health system for the 21st century,” the Institute of Medicine explicitly encourages SDM, recommending that patients “be given the necessary information and the opportunity to exercise the degree of control they choose over health care decisions that affect them [
The following definition of SDM emerged from the 2016 Academic Emergency Medicine Consensus Conference on the topic: “A conversation between…clinician and…patient in which they figure out together what to do to address the patient’s situation [
SDM is no less applicable to EM than to other specialties, in all but the most immediately life-threatening situations [
Evidence of the benefits of SDM comes mostly from studies using decision aids (DAs)—visually accessible information displays in a variety of formats aimed at facilitating SDM. A large Cochrane review found that, compared with those getting usual care, patients who use DAs demonstrate greater knowledge, more accurate perception of treatment benefits and harms, and less tendency to remain passive during decision making, and they experience no greater anxiety [
Importantly, informed patients encouraged to consider their preferences appear to choose more conservative options. Patients with back pain who watched a video of other patients explaining their treatment preferences were less likely to choose surgery than patients receiving only written information; 1-year outcomes were the same [
Studies of DAs in the EM literature support this finding. In one, ED patients with chest pain or dyspnea were presented with a hypothetical scenario involving a standardized description of the workup for possible pulmonary embolus, along with a DA describing the risks of CT in low-probability patients and of deferring imaging assuming a D-dimer less than twice the upper limit of normal; over a third of patients elected to defer imaging [
SDM is far from a guarantee of less extensive testing. In fact, concerns have been raised that linking it to the hope of greater efficiency could detract from its intended focus on patients’ interests [
Most patients favor at least some level of involvement in health care decisions. An overwhelming majority wish to be offered choices and to be asked their opinion; interest in helping make the final decision varies somewhat but is nevertheless substantial [
The reasons for variable patient interest in SDM are worth considering. For example, some patients cite authoritarian physician style and a fear of being labeled difficult as factors [
In a 2016 survey, SDM was endorsed by a majority of709 EPs across a range of decision categories, including invasive procedures, diagnostic testing (particularly CT scans), medications, and disposition [
Still, EPs estimated that they use SDM only 58% of the times it would be appropriate [
SDM faces several challenges. Vulnerable populations are one: patients lacking health literacy and in other ways disadvantaged have been found less willing to participate in medical decisions [
A second potential hurdle is that SDM is widely believed to require physician education and training [
Probably the greatest difficulties for SDM, however, are the limitations of physicians’ information base and its application to the individual patient—obstacles to effective and evidence-based practice regardless of the level of patient engagement. Physicians have been found to lack salient and up-to-date knowledge [
Research findings can offer false hope of benefits in several ways. Reversal of standard-of-care practices is common [
Clinical guidelines should in theory provide objective, up-to-date evidence summaries to aid decision making, but two problems currently limit their utility. First, many lack impartiality, due to a heavy presence of financial and other conflicts of interest among guideline authors and panel chairs [
Guidelines should offer flexible approaches and encourage patient engagement, describing potential harms as well as benefits for each approach. Otherwise, they pit individual choice against recommendations that may be held up as a standard of practice, creating tension for physicians and patients alike. DAs were created to address this need. They are becoming available online in increasing numbers (
Hoffmann et al [
Information provided to patients should be presented at a level of detail commensurate with patients’ interest and intellectual ability, and, where knowable, with the potential significance to the patient of the choice to be made. Caverly et al. [
What if the patient wants care that will not help? Fenton et al. [
What if instead the patient declines care that the physician feels is important? For example, when the risk of serious disease is low but the stakes are high? Situations will inevitably arise in which a patient’s decision creates discomfort for the physician. With or without SDM, patient autonomy amounts to the freedom to refuse care, assuming a patient has decisional capacity and is sufficiently informed. A systematic review on the question of whether SDM influences medical malpractice litigation found insufficient empirical data to draw conclusions, but some evidence suggested that disregard of patient preferences and failure to provide information increased risk [
When a physician is uncomfortable with a patient’s decision, additional safeguards should be utilized where possible, such as ED observation or early follow-up, and the discussion should be documented. SDM should in general be documented, though there is as yet no standard approach for doing so.
Many nonpatient factors influence medical decision making. Overwhelmingly, these tend in the direction of encouraging more health care. The result is often medically unnecessary care, or overuse, which not only adds needless cost but exposes patients to avoidable risks. Physician assumptions about patient preferences also affect medical decisions and contribute to unnecessary care. These assumptions are wrong surprisingly often, and even when correct overlook two of patients’ most consistent priorities: communication and empathy by their physicians. By providing balanced information so patients understand their options and any trade-offs involved, encouraging them to voice their preferences and values, and engaging them (to the extent appropriate or desired) in decision making, physicians are in a better position to address patients’ concerns without the use of tests and treatments patients neither need nor value.
No potential conflict of interest relevant to this article was reported.
Common forms of overuse in emergency medicine as identified by American College of Emergency Physicians for the Choosing Wisely initiative
Computed tomography (CT) scans of the head in emergency department patients with minor head injury who are at low risk based on validated decision rules. |
Placing indwelling urinary catheters in the emergency department for either urine output monitoring in stable patients who can void, or for patient or staff convenience. |
Failure to engage available palliative and hospice care services in the emergency department for patients likely to benefit. |
Antibiotics and wound cultures in emergency department patients with uncomplicated skin and soft tissure abscesses after successful incision and drainage and with adequate medical follow-up. |
Instituting intravenous fluids before doing a trial of oral rehydration therapy in uncomplicated emergency department cases of mild to moderate dehydration in children. |
CT of the head in asymptomatic adult patients in the emergency department with syncope, insignificant trauma and a normal neurological evaluation. |
CT pulmonary angiography in emergency department patients with a low-prestest probability of pulmonary embolism and either a negative Pulmonary Embolism Rule-Out Criteria or a negative D-dimer. |
Lumbar spine imaging in the emergency department for adults with non-traumatic back pain unless the patient has severe or progressive neurologic deficits or is suspect- ed of having a serious underlying condition (such as vertebral infection, cauda equina syndrome, or cancer with bony metastasis). |
Prescribing antibiotics in the emergency department for uncomplicated sinusitis. |
Ordering CT of the abdomen and pelvis in young otherwise healthy emergency department patinets (age < 50) with known histories of kidney stones, or ureterolithiasis, presenting with symptoms consistent with uncomplicated renal colic. |
Decision aids: on-line resources
The MAGIC Project |
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The Dartmouth-Hitchcock Center for Shared Decision Making |
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The Mayo Clinic Shared Decision Making National Resource Center |
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The International Patient Decision Aid Standards Collaboration |
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Questions to guide shared decision making
What will happen if we wait and watch? |
What are your test or treatment options? |
What are the benefits and harms of these options? |
How do the benefits and harms weigh up for you? |
Do you have enough information to make a choice? |
Reproduced from Hoffmann TC, et al. Med J Aust 2014;201:35-9, with permission from the Medical Journal of Australia. [
A 6-step approach to fielding patient requests for low-value diagnostic tests
Understand the patient’s concerns and expectations before addressing them |
Validate the patient’s concerns and emotions using empathy and normalization. |
Inform the patient about reassuring features of the history and examination. |
Explain that you do not recommend the test because risks outweigh benefits. |
Flexibly negotiate alternatives to testing. |
Explore for residual concerns. |
Reproduced from Fenton JJ, et al. JAMA Intern Med 2016;176:191-7, with permission from the American Medical Association. [