Missing an Obvious Cause of Medical Overuse

This post introduces my latest column over at Medscape. I hope you go read the full piece. 

Medical overuse bothers me. Consuming medical care that does not improve outcomes makes you poorer, and puts you at risk for being harmed. 

I think a lot about why Americans consume more healthcare than our peers in other countries. This would be a no-brainer if excess spending led to better health. But it doesn’t. 

If you consider healthcare as a simple transaction for health, excess consumption without better outcomes forms a puzzle.

I have written before about the most obvious reasons American healthcare is so wasteful: profit motives of doctors and hospitals in a fee-for-service system, the human bias for action over watchful waiting, and ignorance of medical evidence. 

But maybe there is another more basic force at play. What if it comes down to the hidden motives embedded within human behavior? 

Over the holidays I read a terrific book called The Elephant in the Brain by Kevin Simler and Robin Hanson. It felt like a Eureka moment.

The writers’ core idea is that humans are social animals competing for power, status and mates. Due to evolutionary and social forces, humans are not only capable of acting on hidden motives, the authors write that we are 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.” 

In short, we signal. Three examples: 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.

How does signaling apply to medical overuse? The authors use the example of the mother who kisses the scrape of her toddler. No healing takes place, but both parties appreciate the ritual. Key word: ritual. The ritual is conspicuous caring. 

Think about it: If healthcare was only about health, you would expect people to pay for, and clinicians to prescribe, only treatments in which benefits exceed costs. But conspicuous caring provides a (hidden) reason for demand that leads to consumption beyond the point of value.

The family who pushes the elderly parent to accept aggressive chemotherapy and the healthy executive who insists on silly heart imaging tests. These are signals of conspicuous caring. AF ablation has yet to be proven effective in a placebo-controlled trial. Yet, due its invasive nature, it puts out a big signal of conspicuous caring.

Such hidden motives explain a number of observations. 

Conspicuous caring explains why people shun simple remedies, such as stress reduction and better diet, but embrace fancy care with showy gadgets. (Think robotic surgery.)

Conspicuous caring explains the focus on public rather than private signs of medical quality. For instance, people still prefer doctors over advanced practice professionals for primary care—even though trials show similar outcomes.

Conspicuous caring motives also predict society’s reluctance to openly question medical quality. To the degree that medical care serves as a gift, it breaks a norm to question its quality. References: second opinions are uncommon and skeptical views of medicine carry a bit of a taboo.

The reason I wrote about Simler and Hanson’s idea is that for twenty years of practice I have missed the elephant in the room—or in this case, the elephant in the brain. Of course, John, human behaviors surely lie at the core of why we accept so much low-value care.

The other reason why this idea is important is that policies that ignore hidden motives may completely fail.

Take a look at my column. Read the book.

Let me know what you think.