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.
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 patient.”1
Do No Harm Project:
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 Competition2
· Recognized by the Lown Institute as a key program to help trainees around the country reduce
medical overuse and improve patient care
of the John Tooker Evergreen Award by the American College of Physicians, 2014
· A convenient way to meet the aims of the CLER (Clinical Learning Environment Review) program from ACGME
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
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.
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