The full content of Annals is available to subscribers

Subscribe/Learn More  >
Ideas and Opinions |

Faded Promises: The Challenge of Deadopting Low-Value CareThe Challenge of Deadopting Low-Value Care

Benjamin R. Roman, MD; and David A. Asch, MD, MBA
[+] Article, Author, and Disclosure Information

This article was published online first at www.annals.org on 29 April 2014.

From the Robert Wood Johnson Foundation Clinical Scholars Program and the Leonard Davis Institute of Health Economics, University of Pennsylvania, Center for Health Equity Research and Promotion, Philadelphia Veterans Affairs Medical Center, Philadelphia, Pennsylvania, and Head and Neck Service, Memorial Sloan Kettering Cancer Center, New York, New York.

Acknowledgment: The authors thank Peter Bach, Jon Baron, Jack Hershey, George Loewenstein, and Victor Fuchs for providing valuable comments about earlier versions of this manuscript.

Financial Support: In part by the Robert Wood Johnson Foundation Clinical Scholars Program.

Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M14-0212.

Corresponding Author: David A. Asch, MD, MBA, Blockley Hall 1123, 423 Guardian Drive, Philadelphia, PA 19104; e-mail, asch@wharton.upenn.edu.

Current Author Addresses: Dr. Roman: Blockley Hall 1303, 423 Guardian Drive, Philadelphia, PA 19104.

Dr. Asch: Blockley Hall 1123, 423 Guardian Drive, Philadelphia, PA 19104.

Author Contributions:Conception and design: B.R. Roman, D.A. Asch.

Analysis and interpretation of the data: B.R. Roman, D.A. Asch.

Drafting of the article: B.R. Roman, D.A. Asch.

Critical revision of the article for important intellectual content: B.R. Roman, D.A. Asch.

Final approval of the article: B.R. Roman, D.A. Asch.

Administrative, technical, or logistic support: B.R. Roman, D.A. Asch.

Collection and assembly of data: B.R. Roman, D.A. Asch.

Ann Intern Med. 2014;161(2):149-150. doi:10.7326/M14-0212
Text Size: A A A

This commentary discusses the difficulty in ceasing practices that physicians have come to believe in despite evidence showing that those practices have little value. The authors suggest several approaches to lessen patient dissatisfaction when attempting to discontinue entrenched low-value practices.

First Page Preview

View Large
First page PDF preview





Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Submit a Comment/Letter
Posted on July 24, 2014
Frederic H. Schwartz, MD, FACP
University of Massachusetts School of Medicine
Conflict of Interest: None Declared
I read Drs. Roman and Asch's article with great interest and wish to share my perspective on runaway health care costs and their sources with the Internal Medicine community. While psychological forces may be at play in the deadoption process of chemotherapeutic agents, procedures and technologies, I do not believe this to be a significant factor in causing runaway costs. Rather the major etiology is the pervading culture that emanates from what Arnold Relman, MD described as the "medical industrial complex". The American College of Physicians has taken a bold and important initiative with their new emphasis on introducing value training for graduate trainees in Internal Medicine. Unfortunately, the problem begins in medical schools where students are seduced by the lures found within the hollowed walls of technology and cutting edge procedures.

I believe that the Hippocratic Oath needs to be reworked to include the necessity of always striving to provide patient care in the most cost effective way possible with the goal of providing the "greatest good for the greatest number". It needs to be emphasized that providing "cost effective" and medically appropriate care for patients is as important as having compassion for patients and their families, acquiring the necessary training and expertise, continuing medical education and being leaders of the health care team. It is imperative that this new culture is adopted not just by primary care physicians but by specialists as well. Medical students, physician assistant students, nurse practitioner students, interns, residents, and fellows must learn that they are being judged by their mentors and teachers not only by their ability to perform a procedure but also by having the skill to know when and why that procedure is medically appropriate. For example, when I trained in the mid 1980s it was almost de rigeur to order as many tests as one could think of when working up a patient for an undiagnosed illness. Think of the elderly patient with dementia who is seen by a neurologist who orders a HIV, Lyme, RPR, ANA, ESR, EEG and MRI. No wonder that gynecologists were able to promote unnecessary annual check ups (including PAP smears) for years. The public has been convinced that more is better and a sign of caring by the physician when the reality is that physician's motivation was often based on what was best for their business and bottom line. I will never forget reading in the Annals in the late 1980s that PAP smears in the average risk woman can be safely spaced three years apart assuming they are normal each time and then experiencing the real world where woman were typically receiving PAP smears on an annual basis even when they did not have cervixes.

Until the medical community chooses to add "cost effective care" as one its core values for all specialties, the United States will continue to lead the world in health care costs per capita. Unfortunately, as we all know, spending the most has not, and never will, translate to providing the highest quality care.

Author's Response
Posted on August 26, 2014
Benjamin R. Roman, MD, MSHP, David A. Asch, MD, MBA
University of Pennsylvania
Conflict of Interest: None Declared
We agree with Dr. Schwartz that high costs have many origins. However, our main point was that addressing medical overuse will require more than just setting new standards of appropriateness and providing education and guidance toward those standards. Our difficulty giving up low value services arises less because physicians might be self-interested or socialized toward the wrong goals, and more because physicians are human, and susceptible to characteristically human errors in thinking. These include optimism bias, confirmation bias, loss aversion, the affect heuristic, and perhaps other decision processes that are not the products of reason but reflections of our psychological foibles. By all means, let’s teach and socialize our physicians toward economically prudent care. Let’s recast professional standards to include value. But unless we also acknowledge and learn to circumvent our deeply seated psychological biases we shouldn’t expect any of these approaches to get us much closer to our goals.

Submit a Comment/Letter

Summary for Patients

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.


Buy Now for $32.00

to gain full access to the content and tools.

Want to Subscribe?

Learn more about subscription options

Related Articles
Topic Collections
PubMed Articles
Brain health: time matters in multiple sclerosis. Mult Scler Relat Disord 2016;9 Suppl 1():S5-S48.
HW 04-1 USEFULNESS OF BIG DATA IN CLINICAL RESEARCH. J Hypertens 2016;34 Suppl 1 - ISH 2016 Abstract Book():e539.
Forgot your password?
Enter your username and email address. We'll send you a reminder to the email address on record.