A zero tolerance for error and uncertainty drives the culture of overdiagnosis and overtreatment, say two senior US doctors in The BMJ.

Professor Jerome Hoffman and Veterans Affairs/Robert Wood Johnson fellow Hemal Kanzaria from the University of California argue that efforts to reduce overdiagnosis and overtreatment "should focus on changing professional and public attitudes towards medical error and uncertainty."

There are many reasons why physicians engage in overtesting and overtreatment, including perverse financial incentives and commercial marketing efforts designed to create demand for more testing, diagnosis, and treatment.

Physicians themselves mostly cite fear of legal (malpractice) claims as the primary driver of success. But the authors argue that malpractice reform will not be sufficient to resolve this problem.

Instead, they suggest that intolerance of both uncertainty and error - among physicians, in the larger medical culture, and in general Western culture - may be the most important reason that physicians engage in medical excess. "Both need to be confronted if we are to tackle the problem of "too much medicine," they say.

They call for action "to change both the incentives that currently reward overtesting and overtreatment, and the disincentives of public shaming and potential lawsuits whenever a diagnosis is "missed" or a possible treatment withheld.

They point to efforts already underway, such as the UK's National Institute for Health and Clinical Excellence "do not do" list and the American Board of Internal Medicine's "Choosing Wisely" campaign.

Shared decision making programs have also been shown to lower healthcare costs and usage while maintain high quality care, they add.

"But we need to go beyond these ideas and start to change the culture of medicine, and even the wider culture," they write. "This will require us to be more open about the inevitability of failure, and even of error, and encouraging both the profession and the public to acknowledge and start to define an 'acceptable miss' rate".

They call on physicians to use their authority to educate each other and the public that "information" can sometimes lead to harm rather than benefit; that "catching disease early" does not always translate into better patient outcomes; and, finally, that more is certainly not always better.