Quality Improvement

Medical Trainees Learn to Recognize Clinical Overuse

March 27, 2017 9:57 am

The Do No Harm Project is a simple, reflective writing exercise in which medical trainees, including students and residents, are invited to write a short narrative describing patient harms that occurred—or nearly occurred—because of medical overuse.

Trainees who volunteer to participate receive a day free of clinical duties so that they can focus on writing their vignette. We specifically ask that they steer away from obvious errors or malpractice and instead focus on care that seemed reasonable but was nevertheless avoidable based on scientific evidence or the preferences of a fully informed patient. Participants are required to cite evidence from the medical literature that the care in question was indeed consistent with overuse as well as evidence informing how to do better.

Trainees are encouraged to submit their vignette for publication in JAMA Internal Medicine’s Teachable Moments series so all readers can benefit from shared insights into overuse. Since its inception in 2012, we have had about 100 submissions to the Do No Harm Project, which we believe reflects its popularity and value in the eyes of our trainees.

Filling a Void

The Do No Harm Project was born out of a series of conversations with my friend and colleague Tanner Caverly, MD, MPH—now a general internist and health services research fellow at the Ann Arbor VA Medical Center—while we were internal medicine residents at the University of Colorado School of Medicine. We noticed that patients often received well-intended medical care that was potentially avoidable, and no part of our training curriculum helped with identifying and avoiding such occurrences.

We were inspired by the writings of Dr. Bernard Lown, renowned cardiologist and winner of the Nobel Peace Prize, who advocated for the social responsibility of physicians and the importance of doing “as much as possible for the patient and as little as possible to the patient.”

Of course, we were sensitive to the facts that taking care of patients is hard work and that most of the time the care patients receive is appropriate. But we felt trainees could benefit from increased awareness of the perils of overuse.

To our surprise, there was substantial literature describing the issue of medical overuse, a global problem that in the United States alone is thought to account for more than $200 billion in wasted healthcare-related expenditures annually.

More importantly, real patient harms can occur following services that are unlikely to lead to meaningful clinical benefits. There are many examples. Imagine a patient getting daily complete blood counts while hospitalized—even if the patient’s condition has been stable for several days and the next result is unlikely to influence care management. Or a patient with low-risk chest pain who gets a stress test “just to be sure,” without fully considering the ramifications of a false-positive result. Or a patient with a viral syndrome who receives antibiotics. The trouble with such tests and treatments is that any potential benefit is very small and is likely outweighed by the risk of downstream harms.

Spreading the Word

The Do No Harm Project is supported by the Lown Institute to broaden our reach to students and residents across the country.

One exciting outgrowth has been the Lown Institute’s Right Care Educator Program, which does not involve a written exercise but instead takes place in the traditional clinical conferences in residency programs across the country. With more than 50 participating residency programs to date, we are optimistic that our efforts to enhance education around recognizing and avoiding overuse will continue to grow.

Brandon Combs, MD, FACP, is Senior Fellow for Medical Education, Lown Institute, and associate professor of medicine, University of Colorado School of Medicine, Denver. Read more entries on the Leadership Blog.


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