Author Affiliations: VA Outcomes Group, Department of Veterans Affairs Medical Center, White River Junction, Vt, and the Center for the Evaluative Clinical Sciences, Dartmouth Medical School, Hanover, NH.
The United States has experienced dramatic growth in both
the technical capabilities and share of resources devoted to medical
care. While the benefits of more medical care are widely recognized,
the possibility that harm may result from growth has received little
attention. Because harm from more medical care is unexpected, findings
of harm are discounted or ignored. We suggest that such findings may
indicate a more general problem and deserve serious consideration.
First, we delineate 2 levels of decision making where more medical care
may be introduced: (1) decisions about whether or not to use a discrete
diagnostic or therapeutic intervention and (2) decisions about whether
to add system capacity, eg, the decision to purchase another scanner or
employ another physician. Second, we explore how more medical care at
either level may lead to harm. More diagnosis creates the potential for
labeling and detection of pseudodisease—disease that would never
become apparent to patients during their lifetime without testing. More
treatment may lead to tampering, interventions to correct random rather
than systematic variation, and lower treatment thresholds, where the
risks outweigh the potential benefits. Because there are more diagnoses
to treat and more treatments to provide, physicians may be more likely
to make mistakes and to be distracted from the issues of greatest
concern to their patients. Finally, we turn to the fundamental
challenge—reducing the risk of harm from more medical care. We
identify 4 ways in which inadequate information and improper reasoning
may allow harmful practices to be adopted—a constrained model of
disease, excessive extrapolation, a missing level of analysis, and the
assumption that more is better.
Fisher ES, Welch HG. Avoiding the Unintended Consequences of Growth in Medical Care: How Might More Be Worse? JAMA. 1999;281(5):446–453. doi:10.1001/jama.281.5.446
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