Mission Statement: To promote the art and science of medicine and the betterment of public health by publishing manuscripts of interest and relevance to internists practicing as generalists or as medical subspecialists.

Objective: The Do No Harm Project is a novel reflective writing program that encourages medical trainees to reflect on and write up clinical narratives about instances of avoidable medical overuse. Our goal is to describe this program and to explore the effect of the program on those participating. Methods: Semi-structured interviews were conducted to explore how participating in the project influenced the thinking, attitudes, and behaviors of participating internal medicine residents. Interviews were conducted with 20 out of the 24 participants from the first 15 months of the program. Results: The following themes emerged from our analysis: 1) learning through reflection (with three sub-themes: empathy for the patient perspective, a critical approach to one's own clinical practice, and awareness of the problem of overuse); 2) empowerment to discuss instances of overuse and act before it occurs; and 3) perceptions of enhanced evidence-based practice and shared decision-making. Conclusion: Trainees volunteering to complete a reflective writing exercise perceived improved ability to avoid overuse and improved self-efficacy to change clinical behaviors that do not align with optimal patient care. (c) 2017 Elsevier B.V. All rights reserved.

Unlike goods, which are concrete and easily quantified, services are intangible processes that are produced and consumed concurrently.Health care is a service that can encourage optimal health outcomes only through meaningful, collaborative partnerships between patients and clinicians.Co-production of health services can be used as a means to rethink how health care is delivered not only in the context of face-toface encounters in which the benefits of working together are obvious, but also in designing systems that can improve patient care and enhance value.

High-value care principles can be incorporated into medical education by training medical students to serve as HVC officers during clerkships and to publish their experiences with the potential or actual harms of medical overuse.

Caverly TJ, Prochazka AV, Combs BP, Lucas BP, Mueller SR, Kutner JS, Binswanger I, Fagerlin A, McCormick J, Pfister S, Matlock DD. Doctors and numbers: An assessment of the critical risk interpretation test. Med Decis Making. 2015;35(4):512-524. (Original DOI: 10.1177/0272989X14558423) In the OnlineFirst version of this article, authors Jacqueline McCormick and Shirley Pfister were inadvertently left out of the author list. Their names have been included in the version of the article that appears in this issue. All authors have confirmed their contributions as authors.

Medical overuse is a significant problem, and existing curricula for teaching residents about high-value care are inadequate to meet learner needs. It has been shown that the location where a resident trains is correlated with the ability to provide appropriately conservative care and, thus, presents an opportunity to shape a physician's behavior early in the educational process.1This challenge of medical overuse has been recognized by the Lown Institute in Brookline, Massachusetts, as well as by educators at the Cambridge Health Alliance in Cambridge, Massachusetts, and has given rise to a new educational conference format called “Right Care Rounds.” This conference uses the familiar format of a case presentation to explore and identify drivers of medical overuse and the associated harms in an individual patient case. Goals for Right Care Rounds include helping clinicians recognize and avoid overuse before it occurs, ensuring that the whole patient and the entire continuum of care are considered, and identifying opportunities for improving the quality of care. The Lown Institute provides a framework for the structure of Right Care Rounds (http://lowninstitute.org/take-action/right-care-rounds) and encourages institutions to tailor them to their environment. The case presentation format can be fitted into existing educational time slots such as morning reports, noon conferences, or grand rounds.A recent presentation of Right Care Rounds at the University of Colorado Division of General Internal Medicine used the style of a morbidity and mortality (M&M) conference to present a case of overuse. The case involved a middle-aged man with history of chronic low-back pain treated with opioid medication; this led to secondary hypogonadism and testosterone supplementation. The conference was conducted with 25 participants, consisting of medical students, internal medicine residents, and internal medicine faculty. Key issues presented were the lack of efficacy data for routine testosterone replacement, secular prescribing trends, new evidence suggesting harm from testosterone replacement, and alternative management options for similar cases in the future. These issues were presented to the audience as a means to identify and reflect on the various drivers of medical overuse.To meet the Right Care Rounds goal of fostering discussion among participants, we used a familiar cause-and-effect diagram, or “fishbone,” as a cognitive tool (FIGURE). Unlike a typical M&M conference in which these diagrams are used to identify factors contributing to medical error, our conference highlighted medical overuse as the outcome to be avoided and the focus of future quality improvement initiatives. The example was not intended to present an exhaustive list, yet the 5 categories were used to organize potential contributing factors and ultimately included most drivers identified by the audience.We surveyed the audience using the usual grand rounds evaluation form, a simple 2-item, free-response questionnaire. We asked participants to compare the Right Care Rounds format to prior presentations, and whether the presentation was likely to change practice. Respondents (n = 10) uniformly reported the presentation and discussion to be excellent and indicated that is was likely to positively influence future practice. Although it is difficult to draw conclusions from these preliminary data, the positive response to the Right Care Rounds suggests that this may be an effective method to explore the drivers of medical overuse, the potential harm that results from it, and to offer insight on ways to avoid it in the future.

BACKGROUND:Risk interpretation affects decision making. Yet, there is no valid assessment of how clinicians interpret the risk data that they commonly encounter.OBJECTIVE:To establish the reliability and validity of a 20-item test of clinicians' risk interpretation.METHODS:The Critical Risk Interpretation Test (CRIT) measures clinicians' abilities to 1) modify the interpretation based on meaningful differences in the outcome (e.g., disease specific v. all-cause mortality) and time period (e.g., lifetime v. 10-year mortality), 2) maintain a stable interpretation for different risk framings (e.g., relative v. absolute risk), and 3) correctly interpret how diagnostic testing modifies risk. There were 658 clinicians and medical trainees who participated: 116 nurse practitioners (NPs) at a national conference, 273 medical students at 1 institution, 148 residents in internal medicine at 2 institutions, and 121 internists at 1 institution. Participants completed a self-administered paper test during educational conferences. Seventeen evidence-based medicine experts took the test online and formally assessed content validity. Eighteen second-year medical students were recruited to take the test and a retest 3 weeks later to explore test-retest correlation.RESULTS:Expert review supported test clarity and content validity. Factor analysis supported that the CRIT identifies at least 3 separable areas of clinician knowledge. Test-retest correlation was fair (intraclass correlation coefficient = 0.65; standard error = 0.15). Scores on our test correlated with other tests of related abilities. Mean test scores varied among groups, with differences in prior evidence-based medicine training and experience (93 for NPs, 101 for medical students, 101 for residents, 103 for academic internists, and 110 for physician experts; P < 0.001).CONCLUSIONS:Our results provide supporting evidence for the reliability and validity of the CRIT as an index of critical risk interpretation abilities, which is acceptable and feasible to administer in an educational setting.

A 52-year-old woman with a history of human immunodeficiency virus (HIV) infection receiving highly active antiretroviral therapy (HAART) and with a history of hypertension presented to my continuity clinic reporting several months of dizziness with standing. Her systolic blood pressure was in the high 80s, and daily medications included lisinopril, 80 mg daily; hydrochlorothiazide, 25 mg daily; and metoprolol, 25 mg twice per day. She reported chronic diarrhea from protease inhibitor use, having 3 to 4 loose bowel movements daily for many years. Maintaining adequate hydration had been problematic for her, and she had been hospitalized for orthostatic syncope and dehydration several times over the past year. At the time of her initial visit, her dosage of lisinopril was decreased by half and hydrochlorothiazide use was discontinued. She was referred to the clinical pharmacy for additional medication titration. At her appointment with the clinical pharmacist, blood pressure was noted to be 146/102 mm Hg. Because this was above a presumed target of 140/90 mm Hg, she was once again prescribed a diuretic. After she started using it, she experienced recurrent episodes of dizziness and syncope, which led to hospitalization. Blood pressure management is an essential component of reducing risk of cardiovascular morbidity and mortality.1 Guidelines from the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure2 provide a framework for blood pressure targets and initial drug therapies. The challenge for clinicians is to individualize therapy and find the balance between optimal blood pressure control and the avoidance of adverse effects of medication. In light of our patient’s chronic diarrhea and her propensity for dehydration and orthostasis, diuretic use was likely best avoided. But is there even an appropriate evidence-based blood pressure goal for our patient? There are no specific guidelines for blood pressure control in patients with HIV. Studies have suggested, however, that blood pressure control is particularly important in those with concurrent HIV infection given the chronic inflammatory state of the disease.3 In addition, there is concern that HAART, particularly protease inhibitors, can cause metabolic syndrome and may be associated with increased cardiovascular risk.4 Although optimizing our patient’s blood pressure would be preferred, a more liberal target may have prevented the reinitiation of diuretic therapy and the harms of recurrent symptomatic hypotension and hospitalization. In discussion with her about the risks and benefits of normalizing her blood pressure, she preferred a potential increase in long-term cardiovascular risk over the immediate prospect of harms from hypotension. Of note, it is unclear whether pharmacologically treating patients with mild hypertension but no history of cardiovascular events is beneficial at all, at least over the near term. A Cochrane review5 from 2012 analyzing 8900 participants found that antihypertensive drug treatments over the course of 4 to 5 years did not reduce mortality, cardiovascular events, or stroke, compared with placebo. Nine percent of participants discontinued treatment because of adverse effects.5 This suggests that the most urgent priority for our patient was to prevent the adverse effects of hypertensive medications rather than further lowering her blood pressure. Although prescribing medications is as easy as the click of a button, we must always first consider the individual patient and our obligation to “first, do no harm.” Although blood pressure control is a crucial component of primary care medicine, treating to targets without equal attention to the potential harms from overtreatment can be a risky endeavor.

A columnist at theNew York Times asked readers, “Have you experiencedtoomuchmedicine?”Shereceivedmorethan1000 responses detailing examples ranging fromunnecessary testing and hospitalizations to useless office visits and specialist referrals.1 Patients are not the only ones worried about too muchmedicine: 42%of anational sampleofprimary carephysicians believe that patients in their own practice are receiving too muchmedical care.2 Too much medicine, or overuse, occurs in at least 3 contexts: when benefits from medical care are negligible, when thepotential for harmexceeds thepotential benefit,3 orwhen a fully informed patient would decide to forego the service. Examples of overuse include overtesting (eg, routinely ordering preoperative chest x-rays; see the Perspective in this issue4) and overtreatment (eg, coronary revascularization inpatientswith stable anginanot receivingoptimalmedical therapy). Spending on overuse is thought to substantially contribute to theunsustainablegrowth inUShealthcarecosts.5 Wastefulhealthcare is estimated tocost $750billionannually,6 limiting equitable access tonecessaryhealth care6 andcrowdingout spendingonotherpriorities suchaspublichealth, education, and valuable social programs.When passed on to our patients, health care costs can be financially catastrophic.7 The costs of overuse are not measured in dollars alone. Overtesting and overtreatment expose patients to potential harmsanddownstreamcomplications8—andoften lead tonet harm.Farbeyondcostconsciousness, theethicalcase foravoiding overuse, “first, do no harm,” is a powerful appeal to our professionalism.8 All thoughtful physicians want to minimize harms fromoveruse. The challenge is recognizingwhen an intervention is likely to represent overuse.

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