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April 03, 2016

Penn doctor: 'Therapeutic illusion' leads to inappropriate medical treatments

NEJM paper comes in context of political battle over mounting U.S. health care costs

When patients go to visit a doctor for any number of reasons, it's not uncommon for them to expect to walk out with a prescription or another treatment plan to remedy what ails them. They may even be alarmed if there is no obvious recommendation to address their concerns.

This expectation is the flip-side of what Dr. David J. Cassarett, a professor at UPenn's Perelman School of Medicine, calls the "illusion of control" that leads to costly and often unnecessary medical treatments.

In a perspective paper written for the New England Journal of Medicine, Cassarett evaluates several studies that show physicians consistently report overestimating the benefits of ordering tests and treatments.

“Physicians’ belief that their actions or tools are more effective than they actually are can perpetuate unnecessary and costly care,” Cassarett writes. “Efforts to promote more rational decision making will need to address this illusion directly.”

The paper comes in the context of a political battle over mounting health care costs in the United States, which rose to $3 trillion after a 5.3 percent increase in 2014, according to the Centers for Medicare and Medicaid Services.

Cassarett believes health care costs are driven upward in part by physicians' confusion between the perceived benefits of a treatment tool and patient outcomes that are better attributed to random chance. When doctors determine causality, Cassarett says, they should be advised to consider whether their conclusions come from "a tendency to look selectively for evidence."

The reasons for this tendency, beginning with the expectations of patients, aren't difficult to identify. When reimbursement pressures, quality measures and fear of litigation are taken into account, doctors may err on the side of a "therapeutic illusion" that doing as much as possible is the best way to deliver health care.

To help guide appropriate treatment decisions, Cassarett urges physicians to weigh all available evidence and consider whether any subconscious beliefs – even those tied to past successes with other patients – predispose them to generally favor a particular set of options.

“All physicians can begin to address therapeutic illusion immediately,” Casarett said. “By evaluating their own practice, examining their own beliefs, and applying simple conscious heuristics, all physicians can contribute to more rational, evidence-based care.”

The full NEJM paper, "The Science of Choosing Wisely—Overcoming the Therapeutic Illusion," can be accessed online here

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