Is it really always only the others who are to blame? GP’s view on medical overuse. A questionnaire study

Autoři: Maximilian Pausch aff001;  Angela Schedlbauer aff002;  Maren Weiss aff003;  Thomas Kuehlein aff002;  Susann Hueber aff002
Působiště autorů: Faculty of Medicine, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany aff001;  Institute of General Practice, Universitätsklinikum Erlangen, Erlangen, Germany aff002;  Institute of Psychology, Friedrich-Alexander-University Erlangen-Nürnberg (FAU), Erlangen, Germany aff003
Vyšlo v časopise: PLoS ONE 15(1)
Kategorie: Research Article



Medical overuse is a common problem in health care. Preventing unnecessary medicine is one of the main tasks of General Practice, so called quaternary prevention. We aimed to capture the current opinion of German General Practitioners (GPs) to medical overuse.


A quantitative online study was conducted. The questionnaire was developed based on a qualitative study and literature search. GPs were asked to estimate prevalence of medical overuse as well as to evaluate drivers and solutions of medical overuse. GPs in Bavaria were recruited via email (750 addresses). A descriptive data analysis was performed. Additionally the association between doctors’ attitudes and (1) demographic variables and (2) interest in campaigns against medical overuse was assessed.


Response rate was 18%. The mean age was 54 years, 79% were male and 68% have worked as GP longer than 15 years. Around 38% of medical services were considered as medical overuse and nearly half of the GPs (47%) judged medical overuse to be the more important problem than medical underuse. Main drivers were seen in “patients´ expectations” (76%), “lack of a primary care system” (61%) and “defensive medicine” (53%), whereas “disregard of evidence/guidelines” (15%) and “economic pressure on the side of the doctor” (13%) were not weighted as important causes. Demographic variables did not have an important impact on GPs´ response pattern. GPs interested in campaigns like “Choosing Wisely” showed a higher awareness for medical overuse, although these campaigns were only known by 50% of the respondents.


Medical overuse is an important issue for GPs. Main drivers were searched and found outside their own sphere of responsibility. Campaigns as “Choosing Wisely” seem to have a positive effect on GPs attitude, but knowledge is still limited.

Klíčová slova:

Decision making – Health economics – Medical doctors – Physicians – Preventive medicine – Primary care – Qualitative studies – Questionnaires


1. Welch HG, Schwartz L, Woloshin S. Overdiagnosed: making people sick in the pursuit of health: Beacon Press; 2011.

2. Brownlee S, Chalkidou K, Doust J, Elshaug AG, Glasziou P, Heath I, et al. Evidence for overuse of medical services around the world. The Lancet. 2017;390(10090):156–68.

3. Carter SM, Rogers W, Heath I, Degeling C, Doust J, Barratt A. The challenge of overdiagnosis begins with its definition. BMJ (Clinical research ed). 2015;350:h869. Epub 2015/03/06. doi: 10.1136/bmj.h869 25740625.

4. Hofmann B. Diagnosing overdiagnosis: conceptual challenges and suggested solutions. European journal of epidemiology. 2014;29(9):599–604. doi: 10.1007/s10654-014-9920-5 24880635

5. Chassin MR, Galvin RW. The urgent need to improve health care quality: Institute of Medicine National Roundtable on Health Care Quality. Jama. 1998;280(11):1000–5. doi: 10.1001/jama.280.11.1000 9749483

6. Kelly MP, Heath I, Howick J, Greenhalgh T. The importance of values in evidence-based medicine. BMC Medical Ethics. 2015;16(1):69. doi: 10.1186/s12910-015-0063-3 26459219

7. Morgan DJ, Brownlee S, Leppin AL, Kressin N, Dhruva SS, Levin L, et al. Setting a research agenda for medical overuse. BMJ (Clinical research ed). 2015;351:h4534. Epub 2015/08/27. doi: 10.1136/bmj.h4534 26306661.

8. Kale MS, Korenstein D. Overdiagnosis in primary care: framing the problem and finding solutions. BMJ (Clinical research ed). 2018;362:k2820. Epub 2018/08/16. doi: 10.1136/bmj.k2820 30108054.

9. Morgan DJ, Dhruva SS, Coon ER, Wright SM, Korenstein D. 2017 Update on Medical Overuse: A Systematic Review. JAMA internal medicine. 2018;178(1):110–5. Epub 2017/10/04. doi: 10.1001/jamainternmed.2017.4361 28973402.

10. Unnecessary tests and procedures in the health care system: Choosing Wisely; [cited 2017].

11. Gigerenzer G, Gaissmaier W, Kurz-Milcke E, Schwartz LM, Woloshin S. Helping Doctors and Patients Make Sense of Health Statistics. Psychol Sci Public Interest. 2007;8(2):53–96. Epub 2007/11/01. doi: 10.1111/j.1539-6053.2008.00033.x 26161749.

12. Saposnik G, Redelmeier D, Ruff CC, Tobler PN. Cognitive biases associated with medical decisions: a systematic review. BMC Med Inform Decis Mak. 2016;16(1):138. Epub 2016/11/05. doi: 10.1186/s12911-016-0377-1 27809908.

13. Hofmann BM. Too much technology. BMJ (Clinical research ed). 2015;350:h705. Epub 2015/02/18. doi: 10.1136/bmj.h705 25687230.

14. Hoffmann TC, Del Mar C. Patients’ expectations of the benefits and harms of treatments, screening, and tests: a systematic review. JAMA internal medicine. 2015;175(2):274–86. doi: 10.1001/jamainternmed.2014.6016 25531451

15. Bishop TF, Federman AD, Keyhani S. Physicians’ views on defensive medicine: a national survey. Archives of Internal Medicine. 2010;170(12):1081–3. doi: 10.1001/archinternmed.2010.155 20585077

16. Morgan DJ, Brownlee S, Leppin AL, Kressin N, Dhruva SS, Levin L, et al. Setting a research agenda for medical overuse. BMJ: British Medical Journal. 2015;351.

17. Berwick DM, Hackbarth AD. Eliminating waste in US health care. Jama. 2012;307(14):1513–6. doi: 10.1001/jama.2012.362 22419800

18. Delaune J, Everett W. Waste and inefficiency in the US health care system: clinical care: a comprehensive analysis in support of system-wide improvements: New England Healthcare Institute; 2008.

19. Yong PL, Saunders RS, Olsen L, editors. The healthcare imperative. The Healthcare Imperative: Lowering Costs and Improving Outcomes: Workshop Series Summary; 2010: National Academies Press (US).

20. Starfield B. Is US health really the best in the world? Jama. 2000;284(4):483–5. doi: 10.1001/jama.284.4.483 10904513

21. Schwartz LM, Woloshin S. Changing disease definitions: implications for disease prevalence. Analysis of the Third National Health and Nutrition Examination Survey, 1988–1994. Effective clinical practice: ECP. 1999;2(2):76–85. Epub 1999/10/28. 10538480.

22. Levinson W, Kallewaard M, Bhatia RS, Wolfson D, Shortt S, Kerr EA, et al. ‘Choosing Wisely’: a growing international campaign. BMJ quality & safety. 2014:bmjqs-2014-003821.

23. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perceptions of Choosing Wisely and drivers of overuse. The American journal of managed care. 2016;22(5):337–43. Epub 2016/06/09. 27266435.

24. Kost A, Genao I, Lee JW, Smith SR. Clinical decisions made in primary care clinics before and after Choosing Wisely™. The Journal of the American Board of Family Medicine. 2015;28(4):471–4. doi: 10.3122/jabfm.2015.05.140332 26152437

25. Kuehlein T, Sghedoni D, Visentin G, Guervas J, Jamoulle M. Quartäre Prävention–eine Aufgabe für Hausärzte. PrimaryCare. 2010;10(18):350–4.

26. Kuehlein T, Freund T, Joos S. Von der Kunst des Weglassens. Deutsches Ärzteblatt. 2013;110(48):2312–4.

27. Alber K, Kuehlein T, Schedlbauer A, Schaffer S. Medical overuse and quaternary prevention in primary care–A qualitative study with general practitioners. BMC family practice. 2017;18(1):99. doi: 10.1186/s12875-017-0667-4 29216841

28. von Elm E, Altman DG, Egger M, Pocock SJ, Gotzsche PC, Vandenbroucke JP, et al. Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ (Clinical research ed). 2007;335(7624):806–8. Epub 2007/10/20. doi: 10.1136/bmj.39335.541782.AD 17947786.

29. Eysenbach G. Improving the quality of Web surveys: the Checklist for Reporting Results of Internet E-Surveys (CHERRIES). J Med Internet Res. 2004;6(3):e34. Epub 2004/10/09. doi: 10.2196/jmir.6.3.e34 15471760.

30. Mayring P, editor Combination and integration of qualitative and quantitative analysis. Forum Qualitative Sozialforschung/Forum: Qualitative Social Research; 2001.

31. Alber K, Kuehlein T, Schedlbauer A, Schaffer S. Medical overuse and quaternary prevention in primary care—A qualitative study with general practitioners. BMC family practice. 2017;18(1):99. Epub 2017/12/09. doi: 10.1186/s12875-017-0667-4 29216841.

32. Busfield J. Assessing the overuse of medicines. Social science & medicine (1982). 2015;131:199–206. Epub 2014/12/04. doi: 10.1016/j.socscimed.2014.10.061 25464876.

33. Schwartz AL, Landon BE, Elshaug AG, Chernew ME, McWilliams JM. Measuring low-value care in Medicare. JAMA internal medicine. 2014;174(7):1067–76. doi: 10.1001/jamainternmed.2014.1541 24819824

34. Communication PUR. Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions. Results from a National Survey of Physicians, URL: 2014.

35. Sirovich BE, Woloshin S, Schwartz LM. Too little? Too much? Primary care physicians’ views on US health care: a brief report. Archives of internal medicine. 2011;171(17):1582–5. doi: 10.1001/archinternmed.2011.437 21949169

36. Lyu H, Xu T, Brotman D, Mayer-Blackwell B, Cooper M, Daniel M, et al. Overtreatment in the United States. PLoS One. 2017;12(9):e0181970. doi: 10.1371/journal.pone.0181970 28877170.

37. Gerbera M, Kraftb E, Bosshardc C. Overuse–unnötige Behandlungen als Qualitätsproblem.

38. Unnecessary Tests and Procedures In the Health Care System: What Physicians Say About The Problem, the Causes, and the Solutions. Results from a National Survey of Physicians. Choosing Wisely [cited 2017].

39. SurveyMonkey. [cited 2019].

40. Nielsen J. Usability engineering. Boston: Academic press; 1993.

41. Choosing Wisely [cited 13.08.2019].

42. Smarter Medicine [13.08.2019].

43. Less is more [13.08.2019].

44. Klug entscheiden [13.08.2019].

45. Lavrakas P. Encyclopedia of Survey Research Methods—Forced Choice. 2008. doi: 10.4135/9781412963947

46. Perreault WD. Controlling order-effect bias. The Public Opinion Quarterly. 1975;39(4):544–51.

47. Stocké V. Entstehungsbedingungen von Antwortverzerrungen durch soziale Erwünschtheit: Ein Vergleich der Prognosen der Rational-Choice Theorie und des Modells der Frame-Selektion/Determinants for Respondents’ Susceptibility to Social Desirability Bias: A Comparison of Predictions from Rational Choice Theory and the Model of Frame-Selection. Zeitschrift für Soziologie. 2004:303–20.

48. O’Sullivan ED, Schofield SJ. Cognitive bias in clinical medicine. J R Coll Physicians Edinb. 2018;48(3):225–32. Epub 2018/09/08. doi: 10.4997/JRCPE.2018.306 30191910.

49. Matthias M, Krebs EE, Bergman A, Coffing J, Bair M. Communicating about opioids for chronic pain: A qualitative study of patient attributions and the influence of the patient–physician relationship. European journal of pain. 2014;18(6):835–43. doi: 10.1002/j.1532-2149.2013.00426.x 24921073

50. Buist DS, Chang E, Handley M, Pardee R, Gundersen G, Cheadle A, et al. Primary care clinicians’ perspectives on reducing low-value care in an integrated delivery system. The Permanente Journal. 2016;20(1):41. doi: 10.7812/TPP/15-086 26562308

51. Mayer FS, Duval S, Duval VH. An attributional analysis of commitment. Journal of Personality and Social Psychology. 1980;39(6):1072–80. doi: 10.1037/h0077726

52. Colla CH, Kinsella EA, Morden NE, Meyers DJ, Rosenthal MB, Sequist TD. Physician perceptions of Choosing Wisely and drivers of overuse. The American journal of managed care. 2016;22(5):337–43. 27266435

Článek vyšel v časopise


2020 Číslo 1
Nejčtenější tento týden