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Have We Missed the Hidden Cause of Medical Overuse?

Discussion in 'Family Medicine' started by Dana B, Jan 29, 2019.

  1. Dana B

    Dana B Well-Known Member

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    Annual physical exams, nuclear stress tests for low-risk chest pain, echocardiography for benign palpitations—the list of low-value wasteful medical care is long.

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    Professional societies sanction wasteful practices by publishing ridiculously broad appropriate use criteria.Government payers reward its beneficiaries with free low-value care, such as the "welcome to Medicare" exam. Patients have learned to expect low-value care.

    These are the norms of US healthcare.

    In my struggle to understand overuse, I have considered the obvious: financial conflict of interests of clinicians and hospitals, cognitive bias toward action rather than watchful waiting, and ignorance (willful or otherwise) of medical evidence.

    The Elephant in the Brain
    Perhaps I have overlooked the elephant in the room, or, as Kevin Simler and Robin Hanson write in their terrific book, The Elephant in the Brain . Simler, a computer scientist, and Hanson, an economist and social scientist, propose that hidden motives may be driving the desire to consume and deliver more medicine than is necessary to achieve health.

    Be ready; their core idea may make you squirm. It is that humans are "not only capable of acting on hidden motives—we're designed to do it. Our brains are built to act in our self-interest while at the same time trying hard not to appear selfish in front of other people." This concept provokes because few people eagerly admit that something outwardly kind, such as bringing food to a sick person, may have selfish motives. But the elephant is more than just selfishness; it is a whole cluster of concepts rooted in the fact that we are social animals competing for power, status, and mates.

    "Human behavior," they write, "is rarely what it seems." While many thinkers have made this point, the novelty of Simler and Hansen's elephant is that they apply this to large-scale social issues.

    Some examples of hidden motives and signaling:
    • In education, we say we are going to college to learn, but really, we go to get a certificate to show off our intelligence;

    • In art, we say we appreciate beauty, but really, we use art to signal our cultivated elite status;

    • In charity, we say we give to help people; instead, we use charitable giving to raise our social status and signal our value as an ally.
    The stated reason people seek or deliver medical care is for health. But then four observations by Simler and Hanson suggest a puzzle:

    • In the famous Rand Health Insurance study, people given free healthcare consumed more of it but did not get better health;

    • There exists a general apathy toward nonmedical interventions, like exercise and watchful waiting;

    • Few people show interest in second opinions or outcome statistics; and

    • People readily accept exorbitant and futile care at the end of life.
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