Skip to main content

The Do No Harm Project




I would like to introduce the Geripal community to a wonderful new project that two of my friends and colleagues at the University of Colorado have pioneered. It is called The Do No Harm Project.

Their goal is to emphasize trainee scholarship that highlights the wisdom of Bernard Lown’s credo: ‘do as much as possible for the patient and as little as possible to the patient.’

On their site, they argue, “Harms from overtesting, overdiagnosis, and overtreatment are a serious threat to the health of our patients and the long-term solvency of our health care system. Harms of overuse have not traditionally been taught to medical trainees and there are few incentives to pay attention to overuse: performance measures and payment incentives reward doing more, the legal system punishes underdiagnosis, and there is a dominant cultural belief that more care is better.”

The project is simple - residents submit vignettes where they have witnessed unnecessary harms from overtesting, overdiagnosis, overtreatment, or preference misdiagnosis. Vignettes may also illustrate the benefits of shared decision making. Once per quarter the best vignette is selected by a panel from the Colorado chapter of the American College of Physicians and awarded $50. Annually, each quarterly winner will be considered for case of the year and a $250 prize. Housestaff are encouraged to submit their work to journals and conferences for publication and all participants receive a book illustrating examples of overdiagnosis and evidence demonstrating the importance of its avoidance (Overdiagnosed: Making People Sick in the Pursuit of Health, H. Gilbert Welch).The cases are wonderful to read ranging from overuse of ICU care, unnecessary treatment related to incidental findings, and avoiding unnecessary surgery after engaging in shared decision making.

Personally, I find communicating that more isn’t always better to be one of the hardest things to do. What I love about The Do No Harm Project is the use of narratives - changing the dominant cultural belief that more is better will take more than research and policy, it will take stories.

If you are interested in learning more about the project or if you would like to explore starting something similar at your institution, please don’t hesitate to contact Tanner (tanner.caverly@ucdenver.edu) or Brandon (Brandon.combs@ucdenver.edu).

by: Dan Matlock

Comments

Anonymous said…
There is no mention of malpractice threat in regard to ordering tests and treatments that could likely be avoided or deferred. Nor the demands and preferences of patients and families who agree to testing "just to know" with no regard that the information would likely not change treatment nor outcome.This is particularly true when the patient has medicaid and there is no financial burden to the patient in doing the test. Healthcare reform must address tort reform and some way of educating health consumers of cost/benefit principles regardless of who is paying for the care.
Anonymous said…
Are we then to presume that doing something unnecessary and harmful will reduce risk of litigation? More importantly, do we not have an ethical obligation to educate our patients and engage them in shared decisions? These are the tired arguments that persist in our imperfect system.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Length of Stay in Nursing Homes at the End of Life

One out of every four of us will die while residing in a nursing home. For most of us, that stay in a nursing home will be brief, although this may depend upon social and demographic variables like our gender, net worth, and marital status. These are the conclusions of an important new study published in JAGS by Kelly and colleagues (many of whom are geripal contributors, including Alex Smith and Ken Covinsky).

The study authors used data from the Health and Retirement Study (HRS) to describe the lengths of stay of older adults who resided in nursing homes at the end of life. What they found was that out of the 8,433 study participants who died between 1992 and 2006, 27.3% of resided in a nursing home prior to their death. Most of these patients (70%) actually died in the nursing home without being transferred to another setting like a hospital.

 The length of stay data were striking:

the median length of stay in a nursing home before death was 5 months the average length of stay was l…

Palliative Care in Nursing Homes: Discussion of a Multinational Trial with Lieve Van den Block

Nursing homes are a tough place to do palliative care.  There is extremely high staff turnover, physicians are often not present except for the occasional monthly visit, many residents die with untreated symptoms usually after multiple hospitalizations and burdensome life-prolonging treatments, and specialty palliative care - well that is nowhere to be found in most nursing homes outside of hospice.  So what can we do to improve the palliative care outlook in nursing homes?

On todays podcast we talk with Lieve Van den Block about her recent palliative care intervention that was published in JAMA IM this week.  Lieve led a multicomponent intervention to integrate basic nonspecialist palliative care in in 78 nursing homes located in 7 different European countries.  Just take a moment to grasp the size of this study - 7 counties, 78 nursing homes.  I struggle with just trying to improve palliative care in one site!

We discuss with Lieve the results of the study, her take on why they got…