"Rationing" vs. defensive medicine? New approach is neither of the two

Response is "collective sigh of relief"

Some commonly used diagnostic tests or treatments do not benefit patients, according to the ABIM Foundation's "Choosing Wisely" initiative. "This is not about 'rationing' care," says Christine K. Cassel, MD, president and CEO of the American Board of Internal Medicine and the ABIM Foundation.

"Physicians and the public have been waiting to have this conversation for some time," she says. "The response we've heard signals to us a collective sigh of relief that we are now able to have reasonable conversations about overuse and waste."

Nine participating societies produced a list of 45 tests and procedures physicians and patients should question, including an annual stress test in otherwise healthy adults, chest X-rays before outpatient surgery, and antibiotics for acute sinusitis. (To view the complete list of tests and procedures, go to www.choosingwisely.org.)

"We are not talking about care that would benefit patients, but that which could potentially harm," says Cassel. "Physicians sometimes order tests for defensive reasons. This isn't good for the patient, and it is not good for the health care system."

While there are times when each and every one of these tests is appropriate, the majority of times they are not necessary, she explains.

"Patients and physicians need to work together to integrate the best medical evidence and patients' values and preferences in promoting 'wise' choices about their care," says Steven Weinberger, MD, FACP, executive vice president and CEO of the American College of Physicians.

Weinberger notes that the physician's behavior may be driven primarily by self-interest, such as protection against malpractice litigation, instead of what's best for the patient.

The practice of "defensive medicine" may add to societal costs without benefiting patients or improving their care, adds Weinberger. "How far is it reasonable or appropriate to go, to make sure every possible diagnosis has been explored, even when unlikely?" he asks.

Waste reduced

Rationing refers to withholding care that benefits patients, says Weinberger, while the "Choosing Wisely" approach aims to "do the opposite — withhold care that does not benefit patients."

Eliminated waste in the health care system frees up much-needed resources, argues Cassel. "We could deliver on the promise of accessible and affordable care for everyone in our country who needs it and reduce the burden on consumers and employers," she says.

If providers don't decrease the overuse and misuse of diagnostic testing and treatments, there will be fewer dollars to spend on care that truly helps patients, adds Weinberger. "Thus, when resources are limited, failure to provide rational care actually makes rationing worse," he says.

Providers should utilize the "Choosing Wisely" approach with these practices, says Weinberger:

  • Being informed about areas of potential overuse and misuse of care;
  • Speaking openly with patients about the relative benefits and harm of specific tests and treatments that are overused or misused;
  • Avoiding the ethical pitfalls that often contribute to overuse and misuse of care, such as practicing "defensive" medicine, failing to spend time with patients to explain why something is not recommended, or performing tests and procedures due to financial incentives.

Determine "value" of test

If there is potentially some benefit to a test or treatment, providers must balance individual patient and societal needs, says Weinberger — and these may be in conflict.

The issue of cost effectiveness may be raised, for instance, when trying to determine the "value" of a test. "This is obviously an important issue for some forms of cancer treatment that may provide some limited prolongation of life but have significant cost, as well as toxicity," he says.

The question, says Weinberger, is how much should individual physicians, payers, and society define what is appropriate to spend to extend life by a limited amount?

Similarly, he says, there are ethical issues involving appropriateness of care at the end of life, in particular, "assuring that patients and families understand how much or little such care may be of benefit, and that their values and preferences are known and taken into account."

Open discussion is needed

While it may be easier, and even financially beneficial, for the care team to give the patient the tests he or she wants, it is important to have an open discussion in terms the patient can understand about the real risks and benefits, according to William A. Zoghbi, MD, FACC, president of the American College of Cardiology.

"Testing and treatment decisions should be based on the needs of the individual patient and the best available evidence," says Zoghbi. "Sometimes patients believe more care is better care, or more tests are better. This isn't true."

An important aspect of patient-centered care is talking about the patient's goals, preferences, and options for testing and treatment, adds Zoghbi.

"There are times when 'watch and wait' is better than a test or an invasive procedure," he says. "But 'watch and wait' can be disconcerting to a patient who is worried about their health."

The American College of Cardiology has created guidelines called "Appropriate Use Criteria" for many tests and treatments. These help the cardiac care team and patients tailor the right test to the right patient at the right time, Zoghbi explains.

"The ethics that should be driving our health care and decision making are those pertinent to how best to diagnose and treat patients, with the ultimate goal of improving their health outcome and quality of life," says Zoghbi.


Howard Brody, MD, PhD, John P. McGovern Centennial Chair in Family Medicine/Director, Institute for the Medical Humanities, University of Texas Medical Branch, Galveston, TX. Phone: (409) 772-9386. Email: habrody@utmb.edu.

Christine K. Cassel, MD, president and CEO, ABIM Foundation, Philadelphia, PA. Phone: (215) 446-3500. Email: ccassel@abim.org.