Embargoed for Release: February 2, 1999
Contact: Hali Wickner (603) 650-1520
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More Health Care Is Not Always Better, Say DMS Doctors

LEBANON, NH When it comes to medical care, assuming that more is better may have unintended adverse consequences. Writing in the FEBRUARY 3 issue of The Journal of the American Medical Association two DMS physicians explore the potential pitfalls of ever-increasing medical care and suggest strategies to help avoid harm.

The special communication, "Avoiding the Unintended Consequences of Growth in Medical Care: How Might More Be Worse?" is by Drs. Elliott Fisher, and H. Gilbert Welch, associate professors of medicine and of community and family medicine. Both are members of the medical schools Center for Evaluative Clinical Sciences and the White River Junction Veterans Affairs Medical Center.

"Growth is a major feature of American medicine," say the authors. "For example, over the past two decades the U.S. has seen a doubling in the number of cardiologists and a five-fold increase in radiologists. In this article, we asked ourselves two questions: how might such growth lead to harm? How might we avoid these harms?"

They urge that more effort be devoted to identifying the limitations of current medical practices and to advising physicians about what not to do as well as what to do.

Decisions that lead to more medical care are made at two levels: the discrete, when a physician decides to recommend a specific test or treatment for patient, and the system, when capacity or resources expand, for example by purchasing a new scanner or recruiting another physician. Fisher and Welch identify the mechanisms of harm that could occur at either level as a consequence of more diagnosis, more treatment and having more to do.

As diagnostic technology advances, two potentially harmful problems, labeling and the detection of pseudodisease, will become more common. Labeling is the effect of telling people who feel well that they are sick. Pseudodisease is disease that would never become apparent to patients during their lifetime but for the diagnostic test.

More treatment can lead to harm through lower treatment thresholds. "For example, patients with less severe disease have less to gain from intervention, whether for coronary artery disease to prevent a heart attack or for carotid stenosis to prevent stroke," says Fisher. "If people are treated for inconsequential disease, the risks of treatment will exceed the benefit. Likewise, those with a poor prognosis can be harmed when treatment is pursued," he and Welch say.

Additional treatment can also lead to harm through tampering, which occurs when physicians intervene to try to "correct" a deviation in a physiologic measure that was simply a random fluctuation, such as changing diabetes or high blood pressure medication.

More diseases to diagnose and treat, mean physicians have more to do. With more to do, the complexity of care increases and so does the likelihood of error. Physicians are more likely to be distracted by inconsequential issues and less likely to focus on the problems of greatest concern to their patients.

"Although medicine is increasingly rooted in science, the practice of medicine will remain filled with uncertainty. The fundamental task of physicians, therefore, seems destined to remain one of judgement: how to best apply scientific knowledge to the care of a specific individual such that the benefits are likely to outweigh the harms," they write. "There are four reasons why, however, our judgement may be impaired: a constrained model of disease, excessive extrapolation, a missing level of analysis, and the assumption that more is better."

The article concludes by suggesting specific steps that physicians and policymakers can take to reduce the risk of harm from more medical care: account for the full spectrum of disease so that patients and physicians can make judgements congruent with the increasingly mild disease detected by advanced technology; draw inferences from research studies with care; study the impact of adding new health care resources on the outcomes of care; and, finally, acknowledge the possibility that more might not always be better.

Hali Wickner

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