The Do No Harm Project

Brandon P. Combs, MD, FACPDivision of General Internal Medicine

University of Colorado School of Medicine

Tanner J. Caverly, MD, MPHResearch Fellow, VA HSR&D, Ann Arbor VA Medical Center Clinical Lecturer, University of Michigan School of Medicine

“Once you start thinking about this you see a lot more harms than before .”

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 overuse2) 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

$210

Wait, how much?!

1/3 of the pieWASTED

1/4 of this wasteOVERUSE

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.

“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.”

“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.”

“Reinforced taking a closer look at the evidence.”

“How do you think participating in the DNHP affected you?”

Twitter: @DoNoHarmProjectWebsites

http://www.medschool.ucdenver.edu/gim/donoharmprojecthttp://lowninstitute.org/take-action/the-do-no-harm-project/

THANK YOU!