The U.S. presidential campaign season has reignited debates on how best to deliver cost-effective, high quality care. A new perspective paper in the New England Journal of Medicine advocates for a comprehensive approach to recognize and manage "therapeutic illusion" to improve use of medical treatments. The therapeutic illusion--an unjustified belief in treatment--has been proven in previous studies in different environments. Consistently, physicians have reported overestimating the benefits of inappropriate tests and treatments.
"Physicians' belief that their actions or tools are more effective than they actually are can perpetuate unnecessary and costly care," writes David J. Casarett, MD, MA, a professor of Medicine at the Perelman School of Medicine at the University of Pennsylvania and director of Hospice and Palliative Care at Penn Medicine, and author of the paper. "Efforts to promote more rational decision making will need to address this illusion directly."
U.S. health care spending rose 5.3 percent in 2014 following growth of 2.9 percent in 2013 to reach $3 trillion, or $9,523 per person, according to the Centers for Medicare and Medicaid Services. Although the nation has improved in stats on hospital-acquired infections, number of children receiving recommended vaccines, and other areas, a Kaiser Health System tracker published in September 2015 found the US is still outperformed by other countries in such areas as life expectancy at birth, costs preventing access to health care, and disease burden, among other metrics.
Sometimes what appears to be a treatment's benefit is actually due to random chance, Casarett argues. And this leads clinicians to embrace causality where none exists, or "a tendency to look selectively for evidence" of success of one's clinical decisions.
To combat the therapeutic illusion, the author advocates for conscious steps to counteract subconscious beliefs. For example, before concluding that a particular method of treatment was effective, physicians are urged to look for other explanations of improvements. Also, even if it seems as though a treatment is beneficial, clinicians should test that perceptions by seeking out any evidence that the treatment wasn't effective.
Methods of managing therapeutic illusion should be approached with caution, as "reimbursement pressures, quality measures, fear of litigation, and family expectations" among other factors, can all drive overtreatment. Targeting ineffective treatment associated with therapeutic illusion, without questioning the effectiveness of that strategy, "falls prey to therapeutic illusion itself," the author notes. Research into whether and how managing therapeutic illusion can decrease overtreatment, how therapeutic illusion might actually improve care, and how best to include those results in medical education, is critical.
Casarett cites the Choosing Wisely campaign, in which medical societies identified specific tests, medications and treatments that are sometimes used inappropriately, and updated best practices for their use, for the movement's efforts to reduce inappropriate use of medical treatments and tests, but mentioned a few factors limiting its impact and said "a more comprehensive, broad-based approach is needed," Casarett writes.
"All physicians can begin to address therapeutic illusion immediately," Casarett said. "By evaluating their own practice, examining their own beliefs, and applying simple conscious heuristics, all physicians can contribute to more rational, evidence-based care."
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