Exploring unnecessary invasive procedures in the United States: a retrospective mixed-methods analysis of cases from 2008-2016

Abstract

BackgroundUnnecessary invasive procedures risk harming patients physically, emotionally, and financially. Very little is known about the factors that provide the motive, means, and opportunity (MMO) for unnecessary procedures.MethodsThis project used a mixed-methods design that involved five key steps: (1) systematically searching the literature to identify cases of unnecessary procedures reported from 2008 to 2016; (2) identifying all medical board, court, and news records on relevant cases; (3) coding all relevant records using a structured codebook of case characteristics; (4) analyzing each case using a MMO framework to develop a causal theory of the case; and (5) identifying typologies of cases through a two-step cluster analysis using variables hypothesized to be causally related to unnecessary procedures.ResultsSeventy-nine cases met inclusion criteria. The mean number of documents or sources examined for each case was 36.4. Unnecessary procedures were performed for at least five years in most cases (53.2%); 56.3% of the cases involved 30 or more patients, and 37.5% involved 100 or more patients. In nearly all cases the physician was male (96.2%) and working in private practice (92.4%); 57.0% of the physicians had an accomplice, 48.1% were 50 years of age or older, and 40.5% trained outside the U.S. The most common motives were financial gain (92.4%) and suspected antisocial personality (48.1%), followed by poor problem-solving or clinical skills (11.4%) and ambition (3.8%). The most common environmental factors that provided opportunity for unnecessary procedures included a lack of oversight (40.5%) or oversight failures (39.2%), a corrupt moral climate (26.6%), vulnerable patients (20.3%), and financial conflicts of interest (13.9%).ConclusionsUnnecessary procedures usually appear motivated by financial gain and occur in settings that have oversight problems. Preventive efforts should focus on early detection by peers and institutions, and decisive action by medical boards and federal prosecutors.

Serious Ethical Violations in Medicine: A Statistical and Ethical Analysis of 280 Cases in the United States From 2008–2016

“…Department of Justice 2016). In cases of UIP, patients typically do not know that the invasive procedures performed were unnecessary (DuBois, Chibnall, et al 2017b). In cases of IPCS, patients frequently have substance use disorders and seek the very drugs that are inappropriately prescribed to them (DuBois et al 2016a).…”

“…In a series of recent papers, we reported results from our investigations into the three kinds of wrongdoing. In the first paper, we reported on 100 cases of IPCS (DuBois et al 2016a); in the second, on 101 cases of SAP (DuBois, Walsh, et al 2017); and in the third on 79 cases of UIP (DuBois, Chibnall, et al 2017b). In these three papers, we provide extensive details on our methodological approach.…”

“…In general, our causal coding focused on motives and opportunities, rather than means, for the simple reason that all physicians—often somewhat uniquely—have the means of committing the kinds of wrongdoing we studied: They can prescribe controlled substances; they can ask patients to undress and examine them alone behind closed doors; and they can control the information provided to patients during informed consent, perform invasive procedures, and bill for these procedures. All codes for motives and opportunities are defined and illustrated with UIP examples in Table 4 and Table 5 respectively in our open-access publication on UIP (DuBois, Chibnall, et al 2017a). Finally, within each type of ethical violation, we engaged in cross-case analysis to identify clusters or typologies of cases.…”

Preventing Egregious Ethical Violations in Medical Practice: Evidence-Informed Recommendations from a Multidisciplinary Working Group

“…While rare, the rate of severe disciplinary actions against physicians is nevertheless similar to the rate of new diagnoses of breast cancer each year (1.3 in 1,000) and much more common than new diagnoses of HIV (0.14 in 1,000) — both of which are widely recognized urgent challenges for medicine and public health. 11 Moreover, most egregious violations are never reported to state medical boards, 2,3,12,13 and when they are reported, some boards infrequently take action against a physician’s license. 9,14 Thus, such violations — while uncommon — are undoubtedly far more prevalent than current databases such as the National Practitioners Database (NPDB) indicate.…”

Medical Overtreatment: Friend or Foe?

“…Is this intervention worse than doing nothing or doing less [17]? There may be some debate as to the answer, but there is no debate as to the appropriateness of the questioning for numerous medical [18] and surgical [19] options.…”