The Other Side of Overtreatment: When Clinicians Withhold Care Patients Clearly Need

When the Correct Answer Goes Unchosen

For more than two decades, the dominant narrative in American healthcare quality improvement has centered on doing too much. Unnecessary imaging, redundant laboratory panels, procedures of marginal benefit — these have rightly attracted regulatory scrutiny, payer oversight, and academic critique. Yet a parallel dysfunction has received comparatively little attention: the clinical pattern in which interventions that clearly satisfy evidence thresholds are nonetheless withheld, delayed, or quietly deprioritized.

This phenomenon, sometimes described as appropriate care avoidance, does not arise from ignorance. In many documented cases, the clinician in question is fully aware that guidelines support intervention. The restraint is deliberate — and the consequences for patients are, in aggregate, severe.

Defining the Problem With Precision

Appropriate care avoidance should be distinguished from clinical nihilism, which reflects a genuine belief that treatment is unlikely to help, and from resource-constrained triage, which reflects real-world capacity limitations. The pattern examined here involves clinicians who possess both the knowledge and the means to act but choose not to — typically for reasons that serve institutional or personal risk management rather than patient welfare.

Common drivers include:

• Liability-oriented restraint: Clinicians in high-litigation environments sometimes avoid aggressive intervention thresholds out of concern that adverse outcomes will be attributed to the treatment rather than the underlying condition.
• Outdated mental models: Clinical training imprints decision-making heuristics that do not always update in step with evolving evidence. A physician trained in an era when a given intervention was considered experimental may continue to treat it as such long after guideline bodies have endorsed it.
• Institutional culture: In settings where conservative management is informally rewarded — or where aggressive treatment is associated with peer criticism — clinicians may calibrate their behavior to organizational norms rather than clinical evidence.
• Cognitive load and decision fatigue: Under conditions of high patient volume, clinicians may default to watchful waiting as a low-effort option, even when the evidence profile of the patient clearly warrants action.

Case Evidence: Where the Gaps Are Most Visible

The literature on appropriate care avoidance is not as consolidated as the overtreatment literature, partly because omission is harder to measure than commission. Nevertheless, several clinical domains provide clear illustrations.

Anticoagulation in atrial fibrillation remains one of the most studied examples. Despite well-established risk stratification tools such as the CHA₂DS₂-VASc score, studies published across multiple US health systems have consistently found that a substantial proportion of patients who qualify for anticoagulation therapy do not receive it. In one analysis of Medicare beneficiaries, more than a third of high-risk patients were not anticoagulated at one year post-diagnosis. The downstream consequence — preventable stroke — carries an average cost exceeding $140,000 per event in direct medical expenditures, to say nothing of long-term disability.

Guideline-concordant cancer screening referrals present a similar pattern. Primary care clinicians in underserved and rural US markets have been documented to refer patients for colonoscopy, mammography, and lung CT screening at rates well below what patient risk profiles would indicate. Barriers include time pressure, concern about patient compliance, and in some cases, implicit assumptions about patient priorities that were never explicitly verified.

Sepsis protocol initiation offers a more acute illustration. Despite the broad adoption of the Surviving Sepsis Campaign guidelines and the implementation of mandatory bundle reporting in many US states, studies of emergency department performance continue to identify significant proportions of confirmed sepsis cases where initial fluid resuscitation and antibiotic administration were delayed beyond guideline-specified windows — often in cases where the clinical presentation met established criteria well within the treatment window.

In each of these domains, the omission was not inevitable. It was a choice, shaped by factors that had little to do with the patient's clinical needs.

Quantifying the Harm

Estimating the aggregate burden of appropriate care avoidance is methodologically complex, but available data support a conclusion that the scale is substantial. A 2019 analysis in the Journal of General Internal Medicine estimated that failure to deliver guideline-concordant preventive care alone — across a defined set of high-evidence interventions — accounts for tens of thousands of preventable deaths annually in the United States. When acute and chronic disease management omissions are factored in, the figure grows considerably.

Beyond mortality, the downstream costs are compounding. Conditions that could have been managed at earlier, less intensive stages of progression become more complex and more expensive to treat. Patients who might have maintained functional independence require higher levels of support. Trust in clinical institutions erodes when patients or their families later learn that a recommended intervention was available but not offered.

The Accountability Gap

Current quality measurement infrastructure in the United States is better designed to detect overuse than underuse. Value-based care models and payer audits frequently flag high utilization as a potential quality concern, while underutilization often goes untracked. This asymmetry creates a structural incentive toward omission. A clinician who orders an unnecessary MRI may face scrutiny; a clinician who fails to initiate appropriate anticoagulation typically does not — unless a stroke occurs and the omission is retrospectively examined.

Correcting this imbalance requires deliberate redesign of accountability structures.

Toward Frameworks That Reward Timely Action

The AAPTS Medical Association advocates for a multi-level approach to closing the appropriate care gap:

At the institutional level, health systems should implement omission-sensitive quality metrics alongside utilization metrics. Dashboards that track the proportion of eligible patients receiving guideline-concordant care — stratified by provider, department, and patient population — make the invisible visible. Where gaps are identified, root cause analysis should be standard practice, with findings communicated transparently to clinical teams.

At the clinical level, decision support tools should be designed not only to flag potential overuse but to prompt action when evidence thresholds are met and intervention has not been initiated. Passive alerts are insufficient; active prompts embedded in the clinical workflow — with clear documentation of the clinical rationale when intervention is deferred — create accountability at the point of care.

At the training level, medical education should explicitly address the psychology of clinical omission. Risk aversion, defensive medicine, and the cognitive biases that favor inaction deserve as much curricular attention as the biases that drive overtreatment. Residents and fellows should be trained to recognize when restraint serves the patient and when it serves the clinician.

At the policy level, liability reform that explicitly protects clinicians for guideline-concordant care — regardless of outcome — would reduce one of the most significant structural drivers of appropriate care avoidance. Several US states have introduced safe harbor provisions for evidence-based practice; broader adoption of this model warrants serious consideration.

Rebalancing the Conversation

The commitment to reducing unnecessary care remains important and should not be abandoned. But a healthcare system that is serious about patient welfare cannot focus exclusively on what it should stop doing. Equally rigorous attention must be paid to what it is failing to do.

Every intervention withheld without clinical justification is a harm — quieter than a surgical complication, less visible than an adverse drug reaction, but no less real in its consequences. The AAPTS Medical Association calls on member institutions, clinical leaders, and policymakers to treat appropriate care avoidance with the same urgency that the field has brought to overtreatment. The evidence threshold for action has already been met. What remains is the institutional will to act on it.