Too much medicine,
or medical overuse, occurs when the benefits of an intervention are negligible,
the potential harms of an intervention exceed its potential benefit, or when a
service is provided to a patient who, if fully informed, would have declined
it. Spending on overuse is an important driver of healthcare costs in the
United States and may limit equitable access to necessary care. More
importantly, medical overuse manifesting as overdiagnosis and overtreatment
exposes patients to unnecessary harm. We are ethically obligated to limit overuse when possible. Recognizing
overuse and its downstream harms can be difficult and failing to attend to
potential harms can lead to interventions that are harmful. In the United
States, there is a dominant belief that more healthcare is better – a belief
that is reinforced by financial and legal incentives.
The goal of the Do No Harm Project is to use clinical
vignettes written by trainees to improve recognition of harms that may result
from medical overuse and to drive a needed culture
change in the practice of medicine.
vignettes are a potent way to humanize the harms of medical overuse and provide
a persuasive counterbalance to the “more is better” culture. Beyond
cost-consciousness, “do no harm” is a powerful appeal to our professionalism.
In an era of increasingly depersonalized health care, the Do No Harm Project
promotes the importance of thoughtful, individualized care tailored to the
unique preferences of our patients. To borrow a phrase from Dr.
Bernard Lown, we seek to remind clinicians of the importance of
doing “as much as possible for the patient and as little as possible to the
The Do No
· Recognized by the American Board of Internal Medicine
Foundation for its innovative approach to medical education and named a winner in the national Teaching
Value/Choosing Wisely Competition.2
· A series in JAMA
Internal Medicine called “Teachable Moments” launched September 2013 as a
result of the Do No Harm Project and is dedicated to publishing vignettes
describing harms from overuse from trainees around the country.3
1. Lown B. Social responsibility of
physicians [essay 29]. Presented at: Avoiding Avoidable Care Conference;
Cambridge, Massachusetts; April 26, 2012.
2. American Board of Internal Medicine Foundation. http://www.abimfoundation.org/News/ABIM-Foundation-News/2013/Teaching-Value-and-Choosing-Wisely-Competition-Winners-Announced.aspx. Accessed November 11, 2013.
3. Caverly TJ, Combs BP, Moriates C, Shah
N, Grady D. Too much medicine happens too often: The teachable moment and a
call for manuscripts from clinical trainees. JAMA Internal Medicine. 2013. doi:10.1001/jamainternmed.2013.9967