The Do No Harm Project
“Once you start thinking about this you see a lot more harms than before .”
Brandon P. Combs, MD, FACP
Division of General Internal Medicine
University of Colorado School of Medicine
Tanner J. Caverly, MD, MPH
Research Fellow, VA HSR&D, Ann Arbor VA Medical Center
Clinical Lecturer, University of Michigan School of Medicine
Which scenario probably represents
medical overuse?
A. Pre-operative testing prior to cataract surgery in a
patient who feels well
B. Using insulin to decrease A1C from 7.9 to 6.5 in an
elderly patient with type 2 diabetes
C. Prescribing TMP/Sulfa for UTI in a patient with a sulfa
allergy
D. Patient admitted with NSTEMI is discharged without
aspirin
E. A & B
Origins
– Harms from overuse
occur frequently but
clinicians fail to recognize
– Our goals:
1) promote recognition
of harms from overuse
2) foster local
discussions
3) change local culture
How overuse may manifest
• Overtesting – when benefit of test is nil and
likely outweighed by risks (pap after
hysterectomy for benign dz)
• Overdiagnosis – diagnosing "pseudo-disease”
(screen detected prostate ca in elderly)
• Overtreatment – treating pseudo-disease
harm (bisphosphonate for osteopenia)
• Preference misdiagnosis – treating/testing a
patient who if fully informed would decline the
service (regret after atypical femoral fx)
Why does overuse matter?
1. Harm is the only possible outcome e.g.
20 year old woman has CT chest, 3 in
1000 chance will develop cancer as a
result
2. We have an ethical obligation to avoid
avoidable care
3. $$$
Smith-Bindman R, Lipson J, Marcus R, Kim KP, Mahesh M, Gould R, et al. Radiation dose associated with
common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch
Intern Med 2009;169:2078-86
Wait, how much?!
1/3 of the pie
WASTED
1/4 of this waste
OVERUSE
$210
More on why it matters.
Easy to ignore –may be far downstream e.g.
harm from biopsy of incidental lung nodule 2
yrs after unneeded CT
Labels – patients do worse when
told they are sick
Lots to diagnose with good prognosis if left
alone e.g. 70% of men > 70 yrs have occult
prostate cancer
Coley CM, Barry MJ, Fleming C, Mulley AG. Early detection of prostate cancer. I. Prior
probability and effectiveness of tests. Ann Intern Med 1997;126:394-406
What we are looking for
• Clinical vignettes about 1) overuse resulting in
harm or harm that was narrowly avoided; or
2) misdiagnosis of patient preferences that
subsequently led to overuse and harm, or
harm that was narrowly avoided.
• Emphasize importance of doing “as much as
possible for the patient and as little as
possible to the patient”
Lown, Bernard. Social Responsibility of Physicians (Essay 29). Avoiding Avoidable Care Conference: April 26, 2012
Requirements
Authors: 3 or fewer. The first author must be a trainee
(professional student, intern, resident, fellow, masters or
doctoral student, or post-doctoral student).
Format: 600-800 words, including a clinical vignette headed
“Story from the Front Lines” (an engaging story with enough
clinical information for readers to understand the clinical
issues) and a summary of the clinical issues headed
“Teachable Moment” (succinct summary of the clinical issues,
stating the evidence for overuse and suggesting an alternative
approach).
References: 5 or fewer.
Reasons to participate
• $$ prizes for best vignettes
• Housestaff completing a submission receive a
copy of Overdiagnosed, Making People Sick in
the Pursuit of Health
• Completed submissions posted online for
viewing by your peers.
• Cases are PERFECT for poster presentations,
fulfill scholarly requirement.
• GET PUBLISHED – Teachable Moments, JAMA
Internal Medicine
Narratives written by trainees describing:
(1)unnecessary care resulting in harm or harm that was
narrowly avoided or (2) the misdiagnosis of patient
preferences that subsequently led to unnecessary care and
harm or harm that was narrowly avoided.
Manuscripts should be 600-800 words, provide a clinical
vignette that documents overuse of medical care, and a
summary of the evidence that documents the care provided
was unnecessary.
“How do you think participating in the DNHP affected you?”
“I wouldn’t have learned as much about overuse as quickly as I did and don’t know
that I would have ever devoted the time to thinking/reading about overuse without
doing this.”
“It’s a good opportunity for self reflection and increasing one’s own awareness
around tests/interventions and also to publish and disseminate this information.”
“Once you start thinking about this you see a lot more harms than before .”
“Opened my eyes to the harms that can occur from overtreatment. Was not
something I was taught to consider as a medical student and gave me a lot
more perspective going forward in how I practice medicine.”
“Reinforced taking a closer look at the evidence.”
“I was bothered by harm that was done and writing was a therapeutic experience since
helped me put my feelings on paper and vent in a formal way.” Felt that “I officially filed
my grievance” and “offered closure around the experience.”
THANK YOU!
Twitter: @DoNoHarmProject
Websites
http://www.medschool.ucdenver.edu/gim/donoharmproject
http://lowninstitute.org/take-action/the-do-no-harmproject/