Study population

We recruited 16 participants for the study. Sociodemographics of the study population are shown in table 1.

Table 1

Sample characteristics

Understanding and scope of medical overuse

When asked about the definition of medical overuse, the majority of the participants paused. One participant verbalised this as a question to himself: ‘What have I heard about this?’ (P2, 3441:3473). The hesitant response to the question suggests a low level of presence on the topic of medical overuse. However, most participants were then able to explain the term ‘medical overuse’ in parts: ‘Overuse, meaning that too much is being done. That perhaps too much is offered by physicians, that physicians prescribe too many medications or also prescribe or do too much additional treatment which perhaps would not have been necessary at all’ (P8, 6546:6873). Participants primarily described medical overuse as overprescribing and providing services beyond what is necessary (P4, 14111:14264). Participants mentioned the aspect time: ‘instead of waiting it out first’ (P1, 4623:4881), physicians act too quickly. Few participants addressed overuse in terms of overdiagnosis: ‘And that’s where the likelihood of therapy based on a finding like that is going to affect your life, seriously impairs your life, […], which must be weighed against the decision: I'm not going to do anything now. So, I don't even have a diagnosis yet and I can still be more or less healthy, (have) symptom-free life for another 10 years, and then at some point, I die when I am old’ (P6, 4964:5426). For this participant, the emotional and physical damages resulting from the diagnosis sometimes exceed the benefits that might result from an early diagnosis. Another participant added that medical overuse means the unnecessary repetition of procedures: ‘For example—blood tests, laboratory checks that the GP may have already performed and then the specialist does it again, stories like that’ (P2, 7050:7207).

Medical overuse also depends on the perspective: ‘For the patient himself, one could sometimes say, yes, he needs it. Others might say, you don't need it, for example, my blood glucose scanner, you might say, well, he doesn't need it. It can also be done with a normal blood glucose meter and then you could say that it is medical overuse in quotation marks. But if one is now in the situation, I would say, I would need it nevertheless, because thereby […] my life with the illness becomes simpler’ (P9, 19043:19691). Meaning, if the procedure benefits the patient, it is not perceived as medical overuse from the patient’s point of view. For others, however, the additional costs may exceed the objective benefit—in other words, there may be economic overuse.

For a few participants, medical overuse also means having resources that exceed real needs, for example, too many physicians/hospitals (P4, 13368:13503; P 10, 8:9). In addition, the wasteful use of resources was also defined as overuse: ‘Well, in my career (as a nurse), as a student and then, later on, we had to sterilize syringes and cannulas ourselves, […] we didn't have so many garbage bags per day’ (P2, 26433:27047). Medical overuse is to be understood as a lack of appreciation for resources, which leads to irresponsible use of them.

Only one of the 16 participants stated at the beginning that he had already had experiences with medical overuse himself. In the course of the interviews, however, all participants were able to report their own experiences with medical overuse, but mostly the experiences of others (friends, family members). The sensitivity of being oneself exposed to medical overuse seemed to be rather low. As an example, two (separately conducted) interviews within one family can be mentioned. The mother reported that she has always been very careful to receive only necessary measures (P10, 130:145). The daughter explicitly mentioned her mother, who often has unnecessary medical measures performed (P11, 51:65). There are only a few moments when the participants rated their medical care as overuse. For example, one participant reported about his prostate surgery: ‘[…], if I had known, I wouldn't have agreed, I basically replaced the plague with cholera’ (P7, 27944:28161).

Medical overuse is perceived primarily in the context of screening, imaging, medications and operations. Screening examinations were a frequent topic in the interviews and therefore appeared to be particularly relevant to participants. Some participants classified screening to detect colorectal cancer (P6, 22909:23215), breast cancer (P1, 12353:12481) or prostate cancer (P6, 4127:4415) as medical overuse. According to the participants, this attribution is relativised by the individual benefit/harm balance for the patient: some patients benefit from an early cancer diagnosis, whereas other patients experience unnecessary consequences due to overdiagnosis (P6, 4127:4415): ‘So not all 50-year-olds or all 60-year-olds should be examined every two years or every four years’ (P6, 22909:23215). Screening examinations are often perceived to be offered by creating fear combined with the promise of a long and healthy life: ‘I think that physicians are creating a lot of fear […] they make them [= patients] believe that if you have the check-up every two years or every half a year, then you will live to be 100 years’ (P6, 456895:7038). Experience with medical overuse of imaging was high among participants: ‘Too many imaging exams are done’ (P2, 5524:5597). The participants believed that imaging examinations are often used to compensate for the lack of medical history taking and physical examination.

Pharmacotherapy was also mentioned as frequently being unnecessary; specifically unnecessary prescriptions of antibiotics and polypharmacy in older patients: ‘People in nursing homes (are) getting way too many pills’ (P9, 20413:20702).

Overall, a heterogeneous picture emerged regarding the assessment of how important it is to deal with medical overuse. Some interviewees stated that addressing underuse was more important than reducing overuse (P8, 4539:4678). Other participants believed ‘[…] overuse is almost a day-to-day story because it’s really a lot of things’ (P4, 6404:6694). For the third group of participants, it was hard to estimate if overuse is a common problem in Germany (P1, 37726:37869). Especially for this third group, participating in the study led to reflecting and thinking about the topic which they also expressed throughout the interviews.

Direct driversPatient characteristics influencing medical overuse

Four groups of patients were identified by the participants who are particularly affected by overuse: (1) privately insured patients (P3, 12261:12447), (2) seriously ill patients in the dying process (P5, 20757:21489), (3) older multimorbid patients as today’s high life-expectancy increases their risk of being affected by medical overuse (P9, 36586:37401) and older patients in general who are more likely to behave in a physician-compliant manner, not questioning unnecessary measures and (4) generally anxious patients who ‘simply need more to feel safe’ (P3, 31376:31549). Especially anxious patients focus too much on their illness: ‘[…] and go to the physician all the time’ (P2, 16056:16516). This often goes hand in hand with doctor shopping ‘they also make a sport out of going to the physician’ (P1, 27790:28024) or seeing specialists directly rather than GPs. Some participants reflected that they might have been drivers of overuse themselves: ‘I was somehow a bit too worried’ (P7, 41304:41511). Their responsibility always went along with uncertainty or anxiety. Uncertainty on the physicians’ side was rarely addressed.

Irrespective of these four groups, participants named other factors that may promote medical overuse, for example, the patient’s passive demeanour toward the physician: ‘I also have friends who then all of a sudden surrender to this system and say: “Now make me well again, I will do everything you say”’ (P6, 32444:32578). In doing so, the patient enters a relationship of dependency. Some patients also lack confidence: ‘One of our neighbours simply […] didn't agree (with the prescription), but was unable to resist because of her personality. And then she doesn't […] dare to go somewhere else and swallows everything’ (P2, 9671:10057). On the other hand, very independent patients who enter the doctor’s office with a certain expectation may demand services directly from the physician and thus be more likely to be affected by overuse ‘And I sometimes have the feeling that the physicians also adapt a little […] because patients are pushing so hard’ (P8, 28082:28314). Some patients ‘perhaps exaggerate a little because they want a sick certificate’ (P9, 39414:39689). Patients aggravate their symptoms and as a result, the physician sometimes misjudges the health condition and initiates more diagnostics than necessary.

The interviewees often mentioned a lack of awareness of healthcare costs. Reasons for this can be a low education level (P6, 10404:10826), indifference (P4, 51701:51821), language barriers and physical or cognitive impairment (P6, 31542:32094).

Physicians’ expertise is crucial

The participants described physicians as an important driver of medical overuse. Four themes could be distinguished:

Specialty: both GPs (P7, 24095:24259) and specialists (P3, 7744:7817) are involved in medical overuse. However, the number of experiences with overuse among GPs appeared to be rather low compared with specialist care. Here, the participants explicitly named orthopaedic surgeons as an important driver of overuse: ‘The moment you have a few knee problems: “yes, we’ll put in a new prosthesis right away’ (P4, 6523:6695). Participants felt that ‘whenever the opportunity exists, they [= surgeons] will cut’ (P4, 6780:7047).

Lack of professional expertise: a lack of medical expertise can directly lead to medical overuse by performing procedures that are not indicated (P8, 12731:12930). In addition, referrals to a specialist often go hand in hand with a loss of information resulting in double examining.

Accepting limits of medicine: according to a few participants, physicians have difficulty recognising the limits of medicine, leading to interventions that do not bring any additional benefit to the patient (P3, 17427:17582).

Routine: the daily work of many physicians is characterised by ‘[…] routine. And the question of necessity remains somewhat in the background’ (P7, 51441:51830).

Doctor–patient relationship

Lack of time was perceived by many participants as a limiting factor in doctor–patient contact. As a result, the medical history cannot fully be taken. Moreover, lack of time promotes a paternalistic doctor–patient model as medical decisions have to be made under time pressure.

Paternalistic doctor–patient relationship: decisions are often made by the physician alone and therapies ‘[…] are virtually imposed on the patient’ (P3, 16403:16462). There were numerous descriptions of this kind in the data.

Underestimating consequences: physicians and patients are only partially aware of the possible consequences of overuse. They often assume that a diagnostic examination ‘[…] can't be wrong […]’ (P7, 10667:11011). Negative consequences of medical overuse are underestimated and diminish the willingness to prevent unnecessary medicine.

Choice of physician: for some participants, the choice of a suitable physician was largely based on their personal feelings: ‘[…] I naturally choose the physicians who I feel are right for me. And they would never overuse’ (P1, 11127:11253). If the values align with the physician, then patients are less likely to perceive medical overuse.

Indirect driversEconomic reasons as the main driver

All participants named economic factors as a main driver of medical overuse: ‘[…] the healthcare system is more like a business’ (P3, 1686:1848) in which physicians function as ‘entrepreneurs’ (P5, 9714:9890). This has a direct influence on treatment decisions: ‘I do believe that many physicians would treat patients differently if they were not under financial pressure themselves’ (P3, 21293:21446). Defensive medicine increases overuse: ‘I mean, of course, physicians protect themselves. That’s why they'd rather give one too many than one too few’ (P3, 8677:8806).

The participants addressed the misallocation of resources. The current remuneration structures lead to the preferential treatment of certain patient groups and to more medical services and allow physicians to increase their profits in an abusive manner (eg, billing for services not provided). Health insurance companies (P3, 2810:3399) or the pharmaceutical industry primarily act on economic reasons: ‘And I believe that if they (pharmaceutical industry) were to disappear there would be fewer sick people’ (P3, 18232:18645).

Social pressure and unreflected consumption of healthcare services

The participants described a fast-moving society with constant access to healthcare. The constant need to perform demands a healthy person. Accordingly, in the event of illness, some patients preferred simple and fast (meaning medical) solutions. The participants also stated that for most patients, more care is better than less care—patients would rather accept overuse than underuse (P9, 33567:33879). Access to healthcare is taken for granted and consumption is therefore no longer scrutinised (P2, 22947:23368).

Technological progress leads to overdiagnosis and lowers inhibition thresholds

Technological progress constantly leads to new devices (P7,5142:5272). To cover acquisition costs, capacities are fully utilised and medical services are provided partly for economic reasons rather than out of medical necessity (P5, 27823:28652). Due to lower-risk procedures (eg, minimal invasive surgeries), medical overuse is more likely to be accepted as the risk of physical harm is lower (P7, 28590:29001).

ConsequencesHarm to the patient

Overall, participants mentioned consequences of medical overuse, but these statements were significantly shorter compared with other statements which indicates that these consequences might be more difficult for the participants to grasp. Participants mostly named side effects of medication (P3, 7181:7569). The participants also mentioned the negative impact of unnecessary examinations, on the one hand, the short-term consequences, for example, ‘examinations that hurt’ (P5, 8343:8481), on the other hand, long-term damage due to, for example, radiation exposure during mammography screening.

In addition to physical damage, medical overdiagnosis can cause emotional distress to patients. The participants mostly addressed screening examinations here: ‘when the result is positive, at that moment the patient’s life changes completely. And first of all, it changes to the negative’ (P6, 5776:5901). This distress does not only have to be due to the patient’s treatment, but was also described as a result of medical overuse among relatives (P4, 47416:48174).

Damage to the doctor–patient relationship

Medical overuse can raise doubts about the physician’s competence and damage the doctor–patient relationship ‘[…] then you think about whether you want to go there again or (not)’ (P8, 9980:10174). Other than that, they did not report any consequences for the physician and/or the relationship.

Increased costs

The participants mostly mentioned the increased costs in the German healthcare system. ‘The problem we have in general is that all this going to the physician then becomes more expensive […] we keep spinning upwards’ (P4, 35950:38311).

Solutions

The participants felt ‘overchallenged’ (P6, 32846:33004) by the question of solutions to prevent medical overuse. This was expressed by the participants, but it is also reflected in the few and mostly short comments on the topic. Even when proposals for change were raised, doubts about feasibility remained (P6, 13588:13709).

Politics is responsible for the regulatory framework

The participants saw the need of minimising the greed for profit in the healthcare sector as the overriding solution. According to the participants, politics must develop laws to prevent medical overuse. The statements on this remained very vague among the participants.

Personal responsibility

Participants perceived their own behaviour as an essential component in the prevention of medical overuse. Reducing medical overuse ‘[…] starts with oneself and one’s awareness’ (P3, 41033:42099). A central theme here was the patient’s ability to take responsibility for his or her health: ‘[…] I want to have responsibility for myself, also for my body, and I always want to be able to make this decision myself’ (P6, 32101:32279) and they ‘[…] see the physician or the system more as advisory […]’ (P6, 32279:32377). If a patient does not feel well taking care of, he/she should refuse treatment (P5, 9890:10164) and go to another physician (P5, 18021:18135).

A significant part of minimising medical overuse is to avoid contact with the healthcare system in general, for example, by taking preventive measures such as sports: ‘I try to keep it (my body) as fit as possible’ (P1, 8938:9123). The belief in the body’s ability to recover can also—at least in the case of moderate health problems such as an upper respiratory tract infection—delay a visit to the physician ‘My body always regenerates itself because I say, o.k., a cold is something, you just have to get through it, it comes and goes’

Some statements went even further with personal responsibility and stated that patients who cause a lot of unnecessary costs should be held more accountable (P15, 417:418).

More time, more information and shared decision-making

For many participants, a good doctor–patient relationship is crucial to prevent medical overuse. They wish for more time for personal discussion and detailed information about treatment options. To be able to make an informed decision, participants wished for extensive explanations (P2, 11367:11642) and named a partnership model as desirable. Requesting explanations from the physician can promote medical reflection and thus secondarily relativise the urgency of a measure (P5, 7254:7610). If the physician’s explanation did not satisfy the participants, media would be used to seek information.

Health education and incentives to promote a healthy lifestyle

According to the participants, it is important to promote health awareness among the population. As an instrument, the participants suggested ‘[…] broad education should happen’ (P1, 34069:34245), which could be achieved through a variety of offers for all groups of the population. To educate children, for example, ‘[…] health education in school’ could be better (P1, 28958:29083). The participants perceived the media as the motor of education and ‘to influence this positively, yes’ (P3, 36910:37225).

The assessment of certain medical interventions by the health insurance fund can help patients to better understand the advantages and disadvantages. ‘I tend to trust the health insurance companies that represent the general public’ (P6, 1845:2166). None of the participants mentioned information brochures as support for decision-making or knew existing campaigns aiming to reduce medical overuse.

A way to motivate people to lead healthier lifestyles could be to offer financial rewards for prevention from healthcare insurance. ‘So if you do a lot of sports and do a lot for your health, you will of course be rewarded for it’ (P9, 25484:25658). Preventing health issues leads to fewer contacts with the healthcare system and again to a reduction of medical overuse.

Watchful waiting as preferred strategy

If the patient suffers from a disease that requires therapy, physicians should first consider less invasive treatment options, especially when dealing with less severe diseases: ‘So take a sick leave and then have a look and rest and not so much on antibiotics’ (P8, 17842:17928). However, even in the case of more serious illness such as cancer, it is possible to wait for the natural course of the disease with, for example, ‘[…] watchful waiting […] don’t go too quickly into the surgical arena, adopt a watchful waiting attitude’ (P7, 25054:25249). The participant’s knowledge of the precise technical term for watchful waiting in prostate carcinoma indicates that a deep engagement with the topic has already taken place, in this case through his own experience.

Complementary and complementary medicine as treatment option

For a few participants, CAM (complementary medicine) is a significant alternative to conventional medicine. Alternative methods ‘[…] made it possible to omit various medications’ (P3, 49488:49631). They wished for full coverage of costs by health insurance (P3, 50338:50524).

More/less referrals

In order to reduce medical overuse, physicians should use their knowledge in the patients’ best interest. This includes not rashly referring patients to a specialist, but feeling responsible for them themselves. Another participant, on the other hand, thought that medical overuse can be prevented by increasing specialisation, for example in a hospital that ‘[…] only takes care of such cases’ (P8, 13939:14353). This would prevent care given for patients with special individual needs without sufficient qualifications of care givers. The contradiction between the two statements shows the difficulty of meeting the individual needs of each patient.