Medical schools and healthcare workplaces should try harder to change the culture around medical overtreatment, according to Barnett Kramer, MD, MPH.

“Some of the solution may be at the training level of health professionals,” Kramer, director of the cancer prevention division at the National Cancer Institute, in Bethesda, Md., said at a briefing Thursday sponsored by Kaiser Health News. “The number one problem identified by medical historian Kenneth Ludmerer is insufficiency of training for uncertainty in medical school; his thesis was that [this] led to systematic overuse of testing and overtreatment. If neither the physician nor the patient are trained to think [about] and accept uncertainty, then almost always our medical culture is going to lean in one direction, so education in probabalistic thinking [is important].”

Another issue is “knowing when you don’t have to make a decision then and there,” he continued. For instance, “there are situations where we’re learning it’s uncertain what the best way to go is, but there’s pretty good evidence that waiting and seeing what the natural history of the disease is, is acceptable, and sometimes that’s very difficult.”

A third consideration “is to try to keep the discussion focused on what is known about the particular disease,” Kramer said. “There’s a famous saying that ‘If thought corrupts language, the opposite is certainly the case.’ So as soon as you have an entity with the word ‘cancer’ or ‘carcinoma’ in it, sometimes that shuts off the ability to really understand and get informed about what the disease really is.”

“There is some movement … to change the name of some of the things we call cancer,” he added. “If we have enough biological information to know they don’t act like a routine cancer, that at least moves the word off the table and you can focus on what’s known and what’s not known, and try to handle the uncertainties.”

Malpractice liability concerns, especially when combined with clinical uncertainty, also can contribute to overtreatment, said Ranit Mishori, MD, MHS, a family physician and professor of family medicine at Georgetown University here. “There are days when I go home and ask myself again and again and again, ‘Should I have ordered that test? I think I probably shouldn’t have, but is that patient going to sue me?’ God forbid they’ll be the one patient in 1,000 coming down with that rare form of prostate cancer.”

That situation happened to a physician friend of Mishori’s. “He followed all the guidelines about PSA [prostate-specific antigen] testing, and this one person was the person he didn’t test who ended up having prostate cancer and sued the heck out of him,” she said. “Do you think my friend continued with not offering PSA testing to all his other patients? For a while it was a very difficult decision for him.”

Although critics have complained for decades about the problem of physicians overtesting and overtreating because they’re afraid of malpractice suits, not much has changed, Mishori told MedPage Today. She added that the probability of being sued seems to be geographically dependent. “If you’re in rural Arkansas, you’re less likely to be sued, but if you’re in Washington, D.C., and everybody and their sisters are lawyers, it’s something that goes through your mind a little bit more.”

Another problem is that one test often triggers a cascade of testing, said Saurabh Jha, MD, a radiologist and associate professor of radiology at the University of Pennsylvania. He cited a case in which a woman came into the hospital with a suspected pulmonary embolism. A CT scan ruled out that possibility, “but then I did something else which led to cascade of investigations: I measured the main pulmonary artery, and it was 3.3 cm.” Since the threshold for suspecting pulmonary hypertension is 3.1 cm, Jha said in his report that the patient possibly had pulmonary hypertension, and also added the limitations of his conclusion. Because Jha was a resident at the time and most patients passed into others’ care, he then forgot about the case.

Later on, however, another hospital staff member told him that his diagnostic conclusions had resulted in a “cascade of investigations” for that patient. “What I began to realize later on was that the chances of actually picking somebody up with pulmonary hypertension using that number is overwhelmed by causing false positives and putting somebody through a train of investigations,” he said. “Since then, I have begun to be more judicious with measuring, realizing that anything printed in a report can be like a Greek tragedy — very difficult to reverse afterwards.”

Jacqueline Kruser, MD, a pulmonologist and critical care physician at Northwestern Memorial Hospital, in Chicago, called the phenomenon of this testing cascade “clinical momentum.” “We see this for acutely ill patients,” she said. “When they come to the hospital and are admitted to the intensive care unit (ICU), everyone who takes care of you is laser-focused on the acute problems that brought you there … Most importantly, they want to act quickly to fix them, and the environment is designed to fix things rapidly — we can get lab tests back in minutes and rush someone to the operating room in an hour.”

However, although that works well for most patients, “what we worry about is, what about the patients who have different goals [than just getting things fixed] — they want to avoid invasive procedures or burdensome treatment, or they want to be with family, eating what they want to eat?” she said. “All those cascading interventions might not accomplish those goals for that patient.”

The hospital isn’t necessarily designed to focus on those issues, Kruser said. In an ICU, for example, it’s hard to find “enough chairs for everyone to sit down with the patient in the room — with their family, their doctors — and talk about what’s most important to them.”