Much Ado About (Doing) Nothing

An important problem has surfaced in the wake of medical progress: “unnecessary care,” defined as a diagnostic or treatment service that provides no demonstrable benefit to a patient. Remarkably, 30% of all medical care in the United States may meet this definition (1). If so, the medically “overserved” in the United States may outnumber the underserved. Reducing the former inequity (too much care too often for some patients) could free up resources to redress the latter (too little care too late for others).

Unlike other problems in the U.S. health care system, only the medical profession can solve this one. Why? Because physicians' decisions are the proximate cause of unnecessary care (2). Some observers decry this phenomenon as evidence of vice (physicians' greed or laziness). More often, in our view, it is the unintended consequence of virtue (physicians' diligence or humility). When the physician is uncertain, trying to do something (treatment or testing) for all patients who might need it inevitably entails doing that same thing for some patients who might not need it. Whether doing a (normal) laparotomy for a patient with suspected appendicitis or a (negative) screening test for cancer, some nonbeneficial care is the necessary byproduct of optimal clinical decision making.

However, if we simply accept unnecessary care as the inevitable price of clinical uncertainty (and imperfect tests and treatments), we miss an opportunity to move toward a common practice style that reflects shared societal values. This decision-making framework would define “unnecessary care” as that which oversteps an explicit boundary that marks a societal consensus about the optimal balance between “doing something” for patients who (probably) need it and not doing it for those who (probably) do not need it. In a previous article in Annals (3), we used the complementary concepts of “safety” …