Delivering high-value healthcare in the U.S. will require increasing the availability and affordability of needed care and decreasing waste and unnecessary care, much of which is harmful. But there are considerable barriers to reducing unnecessary and potentially harmful care.
One of the barriers, the perception that more medicine must be better, was highlighted by the negative reception of the (USPSTF) recommendation in 2009 advising that mammography posed more harms than benefits for women between the ages of 40 to 50.
The idea for the Less Is More series in JAMA Internal Medicine emerged during our discussion over coffee about the hostile reception to the USPSTF's evidence-based advice. We realized that the message that screening in these women leads to net harms somehow did not come across in the USPSTF messaging, as clearly no one wants harmful procedures.
During that discussion, we talked about the fact that there are many procedures and treatments currently being used that have no known benefit. That means that patients are only exposed to possible harms, and even a small risk is not worth it for no benefit.
But we also realized that there are powerful drivers for more healthcare. The perception has been that more must always be better, right? The culture of medicine is to "do everything possible," preferably with the highest level of technology available, even when this effort sometimes involves harm without much hope of benefit.
Less healthcare stirs fears of rationing, or withholding care simply to save money, perceptions that seemed to drive much of the negative reaction to the USPSTF's mammography recommendation. Doctors and health systems may earn more money when they do more.
We felt that focusing on the harms of overuse and the benefits of less healthcare might counter these forces and educate Americans that there are also often good reasons to "withhold" care.
The Less Is More series was launched shortly after that meeting with To date, we have published 178 articles in this series, including research articles, perspectives from patients and clinicians, commentaries, and the latest addition, the Teachable Moments, which are stories from trainees of an experience that they learned from and can share with others.
The series has had great positive response; many physicians and lay persons have written to thank us for talking about this important issue and for encouraging more research into the harms of tests, procedures, and treatments. The number and range of submitted articles increases every year, and there are so many topics in medicine that would benefit from the lessons of Less is More that we trust this trend will continue.
We are grateful for all of the energy in this area, especially from professional societies joining the American Board of Internal Medicine Foundation's and from the .
Unfortunately, awareness of the harms of overuse of medical care probably isn't enough to achieve the "less is more" goal. We are very encouraged to see that many new efforts are underway to reduce overuse, including educational initiatives, computer-based alerts, and decision support tools, peer review and feedback, and system changes supported by implementation and behavioral sciences.
Important changes are also occurring in the U.S. healthcare system, moving us away from fee-for-service medicine, which rewards high-volume care regardless of appropriateness, towards bundled payments, accountable care organizations, and capitated systems that can better align incentives towards high-value care.
is a cardiologist and professor of medicine at the University of California San Francisco (UCSF) School of Medicine, and Editor-in-Chief of JAMA Internal Medicine. , is professor of medicine, at the UCSF School of Medicine and deputy editor of JAMA Internal Medicine. Redberg and Grady spearheaded the the journal's Less is More series highlighting areas of healthcare with no benefit.