'Therapeutic Illusions' and Choosing Wisely Lapses

'Therapeutic Illusions' and Choosing Wisely Lapses

David Casarett on Physicians' Use of Inappropriate Tests and Treatments

In a New England Journal of Medicine Perspective article, University of Pennsylvania Professor David Casarett cites "therapeutic illusion" as one reason so many physicians continue to use tests and treatments deprecated by the Choosing Wisely guidelines.

Launched in 2012 by the American Board of Internal Medicine Foundation (ABIM) the Choosing Wisely campaign asked professional medical specialist societies to each identify five tests or treatments recognized as ineffective or overused. To date, 70 societies have issued more than 400 recommendations for clinical procedures and drugs considered ineffective or otherwise inappropriate.


David Casarett, MD, Penn Perelman School of Medicine Professor and LDI Senior Fellow.

Wide dissemination
These recommendations are as varied as the names of the societies themselves, which range (alphabetically) from the American Academy of Allergy, Asthma & Immunology to the Society for Vascular Medicine. The ABIM says the Choosing Wisely recommendations -- which have been the subject of more than 10,000 mainstream media articles -- have been widely disseminated.

Nevertheless, a 2014 Robert Wood Johnson Foundation-funded study estimated that the average U.S. physician continues to "order unnecessary medical tests and procedures at least once a week."

The economic impact of billing for unnecessary clinical services is widely recognized to generate a significant portion of the "waste" within the country's annual $3 trillion in health care expenditures.

Inaccurate personal observations
Essentially, Casarett suggests that many physicians believe in certain clinical phenomena that aren't true -- as a result of personal observations that are not accurate.

He says doctors can be like casino gamblers who win a jackpot while wearing a green shirt and thereafter believe there is a connection between that color or shirt  and winning. Clinical events of "random chance," he writes "can encourage physicians to embrace mistaken beliefs about causality."

"Physicians overestimate the benefits of everything from interventions for back pain to cancer chemotherapy," he continued, saying their therapeutic illusion "facilitates the continued use of inappropriate tests and treatments."

Evidence of failure
Doctors, he noted, are often prone to looking only at evidence that confirms what they already believe; however, they should be more vigilant for "evidence of failure" related to their clinical assumptions.

Casarett calls for wider recognition of how therapeutic illusion can skew a clinician's judgement and more research of this issue.

"Strategies to uncover and minimize this bias should be developed and tested in medical school, in postgraduate education and throughout lifelong learning," he wrote.