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Medical Care: When Do Harms Outweigh the Benefits?

June 12, 2015 | Steve Delaronde

Medical care produces both benefits and harms. There are risks associated with care delivered in the hospital, including infections, medical errors and delirium. There are side effects associated with medication and, ultimately, there are risks associated with all medical procedures. When a patient is suffering from a painful or debilitating illness, it is understandable how they might overestimate the benefits of medical care and underestimate its risks in an effort to obtain a cure or symptom relief. More worrisome is that some physicians may be poor estimators of risk. The medical community often ascribes to the adage that it is better to act than do nothing, whereas “nothing” may be in the best interest of the patient.

Patients depend upon their doctors for medical advice. Many simply want to heed doctor’s orders, while others want a greater level of participation in medical decision making. Regardless of the preferences and expectations of patients, physicians have an opportunity and an obligation to provide patients with accurate and complete information on the benefits and harms of tests and interventions.

Understanding benefits and harms extends to screening for disease, as well. Early detection does not come without a price. An article appearing in March 2014 in JAMA Internal Medicine quantifies the benefits and harms of screening mammography. Among 1,000 women who undergo annual population-based screening for 10 years beginning at age 40, as many as 1.6 lives will be saved. What is the price that the others pay for these saved lives? As many as 680 women will have a false positive result and 80 women will undergo a biopsy. Additionally, 11 women will be overdiagnosed and needlessly treated with radiation, chemotherapy and/or surgery. These 11 women that met the criteria for breast cancer would have never experienced symptoms or death from the disease, but were needlessly treated. The situation is only slightly better for 50-year-old women screened annually for a decade. The harms associated with false positive results and overdiagnosis led the American College of Physicians to publish advice to physicians for “High Value Cancer Screening” and a “Framework for Thinking about the Intensity of Screening” in May 2015 that acknowledges the benefits of screening for some, but the significant harms that result for many more.

Before a test or procedure is performed, physicians can offer patients a pretest probability that

  1. a particular test will lead to an actual diagnosis for which there is an effective treatment,
  2. a false positive result will lead to additional tests and procedures, or
  3. overdiagnosis leads to unnecessary and potentially harmful overtreatment.

Physicians can also help patients select a course of action for each possible outcome before ordering a test. Most importantly, physicians can assess their own bias towards offering a test or intervention, which may be rooted in a desire to help patients, but errs on the side of providing more care than necessary.

Accountable care is about aligning incentives, such that the highest quality of care, which often doesn’t mean the greatest amount of care, leads to the most favorable outcomes at the lowest possible cost. This requires that the benefits and harms of medical care be well-understood by physicians and well-communicated to patients.

Steve Delaronde is director of consulting for populations and payment solutions at Solventum.

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Screening
Quality outcomes