Too Much Of A Good Thing Can Harm You
2010; Project HOPE; Volume: 29; Issue: 8 Linguagem: Inglês
10.1377/hlthaff.2010.0671
ISSN2694-233X
Autores ResumoBook Review Health AffairsVol. 29, No. 8: Lessons From Around The World Too Much Of A Good Thing Can Harm YouDavid R. Gifford AffiliationsRhode Island Department of Health David R. Gifford ( [email protected] ) is the director of the Rhode Island Department of Health, in Providence. PUBLISHED:August 2010Free Accesshttps://doi.org/10.1377/hlthaff.2010.0671AboutSectionsView PDFPermissions ShareShare onFacebookTwitterLinked InReddit ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsDownload Exhibits TOPICSHealth servicesOrganization of careHealth care providersSurgeryPhysician-patient relationshipMedical malpracticePatient harmMedical educationHealth reform Norman Rockwell’s paintings had the unique ability to capture the spirit and principles that Americans have traditionally held dear. He frequently depicted the relationship between patient and physician, with the artwork reflecting the trust and value that we still award our physicians. After reading The Treatment Trap by Rosemary Gibson and Janardan Prasad Singh, I believe that Rockwell would not still be painting the same type of pictures today. Somehow those of us involved in health care have drifted away from the values he captured. We’ve forgotten that we entered the health professions to help people stay healthy and cure those who are sick. Like art, storytelling is a method of communicating important principles and values. Gibson and Singh use the power of stories to communicate both what is wrong with our health care delivery system—that physicians have lost sight of that all-important dictum, “First, do no harm”—and what members of the public expect from their health care providers when they place their trust and lives in our hands. Its style is similar to that of an earlier book written by the duo, The Wall of Silence: The Untold Story of the Medical Mistakes That Kill and Injure Millions of Americans (2003), in which they used stories to show how the health care system contributes to medical errors that affect patients and their families. The Treatment Trap delivers an equally powerful message. In this new book, Gibson and Singh discuss health care’s widespread problem of overuse of medical services, which they describe as medical tests such as x-rays or treatments such as surgery or medication. The authors adopt Mark Chassin’s definition of overuse : “providing a treatment when its risk of harm exceeds its potential benefit.” Many of their examples are individuals who had surgery when the indications for that surgery or the benefits to be derived from it were questionable. Although the authors discuss how overuse drives up health care costs, their primary focus is on how overusing medical services can seriously harm patients. We often get numbed by the numbers in medical journals and the general media, but I was pleased to find that Gibson and Singh’s method gives faces and stories to statistics. The authors describe how Mr. Spurgeon had an unnecessary heart bypass; how Mr. Goode received a knee replacement that he didn’t need; and how Lewis B.—a child, whose last name is withheld for privacy reasons— had a congenital chest abnormality “repaired.” All three died from their unneeded surgeries. Gibson and Singh powerfully convey the effect of overused medical services on the very people who have, as the authors say, lain down on the exam table and given their lives over to their doctors.There are also physicians’ stories about the roles played by their uncertainty, beliefs, peer judgment, fear of malpractice suits, and dread of missing a diagnosis. The implications for medical education in this country become clear in the process. The current system drives overuse, which is then reinforced and bulked up, as if on anabolic steroids, by the financial incentives driving overuse—which the authors appropriately call the “green monster.”They also explore the role of the public’s belief that “more is better.” After reading these stories, I believe that the medical community is complicit in our society’s perception that more is the way to go. What is also evident is that little is done by health care professions or society itself to challenge this perception. We are more likely to focus our efforts on underuse and errors of omission than on errors of commission, which include overuse.Gibson and Singh’s stories also make me wonder about other players in the drama. How often has a hospital peer review committee revoked a physician’s admitting privileges because of overuse? Similarly, how often has an insurance credentialing process—or a state medical licensure board—addressed overuse? I suspect that physicians who overuse medical services behave in a way that harms more patients than are affected by all of the adverse outcomes from physicians guilty of underuse, disruptive behavior, and substance abuse combined.Reading this book also led me to reflect on how much of the health care we prescribe has little evidence to support its benefits—and how often we recommend a treatment when the evidence indicates that it might cause harm in the situation at hand.Although many of the stories Gibson and Singh tell are extreme examples of overuse, their book reminds me that the simple act of prescribing antibiotics for a cold—which is likely to be viral rather than bacterial—is an example of overuse. In fact, there are numerous studies on the overuse of antibiotics and its associated harm. Nonetheless, we continue to overprescribe antibiotics. I cannot think of a single institutional review board that would approve a study allowing antibiotics to be prescribed for a virus. This raises the question: Are we practicing unethical medicine when we treat colds with antibiotics? And what does this mean for the many daily tests and treatments we routinely do, when the medical literature provides evidence that the benefit is very low and potential harm exists? What about all of the treatments and tests whose benefits have not been established at all, but that still pose the risk of harm?Gibson and Singh recommend taking ten steps to help halt overuse. One way they suggest for consumers to protect themselves is to ask questions and not take physicians’ recommendations at face value. Many of the steps would be tough to implement because of the green monster, but they are practical and doable. They include not reimbursing providers for medical services that do not work, as well as auditing providers who are outliers on measures of the amount of medical services they use, and reporting the audit results to their patients.The authors’ suggested steps do not rely on technological fixes. Instead, they require leadership in the health care sector. If we put our patients’ health before the interest of the green monster, we can more easily challenge the uncertainties, fears, and other factors driving medical overuse.The Treatment Trap can be read quickly, and it should be required reading for those in leadership positions within the health care delivery, medical reimbursement, and medical education systems. Similarly, for policy makers and those working to implement health reform, this is a must-read book. Health reform either can feed and grow the green monster, or it can put a leash on the monster and train it not to bite the hand that feeds it. My hope is that those who read this book will help make sure that the types of stories it tells are rare occurrences in the future. Loading Comments... Please enable JavaScript to view the comments powered by Disqus. DetailsExhibitsReferencesRelated Article MetricsCitations: Crossref 1 History Published online 1 August 2010 Information Project HOPE—The People-to-People Health Foundation, Inc. PDF downloadCited byOM Forum—The Vital Role of Operations Analysis in Improving Healthcare DeliveryManufacturing & Service Operations Management, Vol. 14, No. 4
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