Healthcare's Third Law

Anyone who has taken even a basic physics class can probably recite -- perhaps with a little prompting -- Newton's Third Law of Motion: "for every action there is an equal and opposite reaction."  Physicians aren't physicists, but something like this is surely applicable to healthcare as well.

If healthcare's first law is "first, do no harm," then the second law would be "do some good."  The third law must then be: "trying to do good can result in doing harm."

The harm may not necessarily be "equal and opposite" to the good, but we can't pretend it isn't there. 

I was reminded about this by a Kaiser Health News investigation on fall prevention, as published in The Washington Post and elsewhere.  The investigation concludes that well-intentioned efforts to prevent falls -- particular in hospitals and nursing homes, and especially for elderly patients -- were resulting in "an epidemic of immobility." 

We've read about epidemics of obesity, diabetes, opioid addiction, even vaping, but an immobility epidemic is not something we hear much about.  We should. 

Fall prevention become a big thing with CMMS implemented penalties for hospital falls; the goal was that falls never happen.  That is understandable; falls can result in serious injuries, including broken hips, concussions, and/or laceration, especially for already fragile patients.  In fact, falls are said to be the leading cause of fatal and non-fatal injuries among the elderly. 

The result of the new penalties, which was not intended but which should not have been surprising -- was a "climate of fear of falling" for hospital staff. 

As a result, more efforts were made to keep patients from moving in order to help assure their safety.  Unfortunately, not moving can be as dangerous as falling.  The article cites Kenneth Covinsky, a UCSF geriatrician, whose research found that one-third of elderly patients leave the hospital more disabled than when they came on.  As Dr. Covinsky said: "Older patients face staggering rates of disability after hospitalizations."

Hospitals and nursing homes have all sorts of alarms when patients try to move on their own, and are required to track falls, but don't track how often patients move.  One study found that previously mobile patients spent 83% of their hospital stay in bed, which helps lead to those disability rates.  Research has shown, and many clinicians acknowledge, that moving during an inpatient is good for patients, but trying to do some good by avoiding falls is leading to the opposite reaction of the "epidemic of immobility."

Here's a second example of healthcare's Third Law, with an equally catchy phrase: how efforts to identify urinary tract infections are creating a "culture of culturing," as posited by Drs. Jerome Leis and Christine Soong in JAMA Internal Medicine last month and expounded on this week in The New York Times.  

Most seniors, it appears, have asymptomatic bacteria in their urine, so when a zealous clinician orders a urine test, odds are high that it will show positive results -- and result in a course of antibiotics.  As Dr. Christine Soong said.  "Once a clinician sees bacteria in the urine, the reflex is, you can’t ignore it. You want to treat it."

Healthcare Second Law in action.  Unfortunately, the Third Law also applies: the United States Preventive Task Force has repeated pointed out, most recently last month, that testing for asymptomatic patients has no benefits but some potential harms.  The Infectious Diseases Society of America and Choosing Wisely also warn about the risks of routine urine tests.  Most urine tests result in unnecessary courses of antibiotics, which contributes to our problem of antibiotic resistance.  

One final example of the Third Law (and I'm sure others could provide endless other examples) comes from oncologist Azra Raza, in a recent WSJ article and new book The First Cell.  Dr. Raza overall rates of cancer deaths have fallen dramatically in the last three decades, but argues that most of this is due to reductions in smoking and increases in screening -- not to better treatments.  

"Status quo treatments...can be brutal and indiscriminate killers," Dr. Raza says.  "Treatments often leave patients in agony, while providing mere months of added survival."  Moreover, she laments: "42.4 percent of the 9.5 million cancer cases had lost all of their life savings within two-plus years," with cancer drug costs "spiraling out of control." 

We're trying to help patients, but Dr. Reza says: "Despite some advances, the treatments for most kinds of cancer continue to be too painful, too damaging, too expensive and too ineffective."

The Third Law in action.  

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A recent BMJ study found that 12% of care, across all medical settings, resulted in patient harm, and that half of that harm was preventable.  It called patient harm a "serious problem," and called for more efforts to track and mitigate it, especially preventable harm.  

An associated BMJ editorial argued: 

Discussions about patient safety describe healthcare as an industry. If that’s the case then what is healthcare’s business? What does it manufacture? Health and wellbeing? Possibly. But we know for certain that healthcare manufactures harm.

Let that last phrase sink in: "Healthcare manufactures harm."  One might as well make that the Third Law.

The editorial goes on to say that: "These data make something of a mockery of our principal professional oath to first do no harm," saying that it is an "impossible oath." It concludes: "First do no harm, it seems, is an ancient oath true in spirit but impossible to practise in the messy business of modern healthcare."

Healthcare is, indeed, a messy business.  We don't always know what is wrong, or why, or what to do about it.  People don't often do what they should, including clinicians, patients, and anyone hoping not to become a patient.  The problems of unnecessary care and medical errors are widely recognized, if not well understood.  But we don't always recognize the potential consequences of healthcare's Third Law, or assume that any harm will only happen to others.

Sometimes, as the Times put it in their review of Dr. Raza's book, we have to know when it is time to say "enough."  Sometimes, as I previously wrote,  we have to stop believing in "magical fairy dust."  But all the time, we should recognize that healthcare's Third Law is out there, waiting for us.

We can't change the laws of physics, and we can't entirely avoid harm coming from care, but we can do a better job of trying to anticipate and minimize that harm.