Unintended consequences: Remember thalidomide

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It was just a few decades ago that thalidomide was prescribed mostly in Europe to control nausea during pregnancy. The result was widespread phocomelia characterized by severe malformation of the extremities. (Lecutier MA. Phocomelia and internal defects due to thalidomide. Br Med J. 1962 Dec 1;2(5317):1447-8.) Thanks to the oversight of the FDA, this drug was not approved in the United States, and American pregnant women avoided this malady in their babies.

In medicine and life, we must be aware of unintended consequences that impact nearly everything we do, including our practice of medicine. Sir Isaac Newton presciently wrote the third law of motion in 1686, which stated that for every action, there is an equal and opposite reaction. Thus, we must consider the unintended consequences when we make decisions on behalf of our patients when we consider a new treatment or when prescribing a new medication. This blog will discuss those unintended consequences in our practice's clinical and non-clinical aspects.

In medicine, every action has the potential to impact patients' lives. While physicians are trained to make informed and evidence-based decisions, the reality is that unintended consequences can still emerge. These consequences may arise from clinical decisions as well as non-clinical choices, and it is essential for physicians to recognize them to ensure the best possible patient care and improve patient outcomes. In this blog, we will explore the concept of unintended consequences from a clinical perspective and examine its impact on non-clinical decisions.

Unintended consequences in clinical settings

Clinical decisions are the bedrock of medical practice. Physicians analyze symptoms, diagnostic tests, and research findings to determine the most appropriate treatment plan for their patients. However, even with the best intentions, unintended consequences can manifest in several ways.

For example, introducing new medical treatments or medications may be hailed as a breakthrough, but unforeseen side effects may emerge over time. For instance, a new drug might effectively target a specific condition but unknowingly exacerbate an unrelated medical issue. Anti-depressants may help with depression, but tardy dyskinesia may occur and require additional medication to relieve this unwanted side effect.

Clinical guidelines are intended to provide a roadmap for patient care. However, these guidelines may not consider every patient's unique characteristics making the guidelines not applicable to every patient. Strict adherence to guidelines without individualization could lead to suboptimal results or harm.

Today, healthcare providers have become dependent upon the use of technology. Before CT scans, MRIs, and PET scans, doctors relied on the physical examination to arrive at a diagnosis. When a patient complains about a specific area of the body, an imaging study is ordered, and the physical exam is often omitted. While these advancements offer numerous benefits, errors in data interpretation or technical malfunctions could inadvertently compromise patient safety. That is why we need to use technology to augment the care of our patients.

Unintended consequences and non-clinical decisions

Beyond clinical practice, physicians are also involved in various non-clinical decisions that impact healthcare. Changes in healthcare policies and regulations can have far-reaching effects. For instance, cost-containment measures might restrict patient access to necessary treatments, leading to adverse health outcomes. For example, with a focus only on costs, the unintended consequence may be rationing of healthcare which most Americans find unacceptable.

Physicians often face time constraints and grueling schedules, leading to decision fatigue and, if not addressed, can result in burnout, impacting nearly 50% of the physician workforce. (Singh R, Volner K, Marlowe D. Provider Burnout. [Updated 2022 Jun 21]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023) Burnout can distract physicians and influence judgment, potentially resulting in poor decisions that yield unintended consequences.

Decisions related to resource allocation, such as staffing, funding, and medical supplies, can inadvertently affect patient care quality and safety. We are faced with declining reimbursements and rising overhead expenses. When practices cut their staff or fail to replace departing staff, the unintended consequence is a deterioration in patient satisfaction and errors entering data resulting in an increase in denials, further reducing practice income.

Avoiding unintended consequences

To make well-informed decisions, we must stay updated with the latest research, advancements, and guidelines. We need to make CME available 24\7 so doctors can experience learning at a convenient time.

Always consider individual patient needs and preferences when developing treatment plans. Patient compliance with medications is important to achieve effective management and enhance outcomes. Approximately 50% of patients(Brown MT, Bussell JK. Medication adherence: WHO cares? Mayo Clin Proc. 2011 Apr;86(4):304-14.)do not take medications as prescribed. Medication compliance can be improved by simply writing down the instructions. Many patients don't retain verbal instructions, which is why it's important to write information down. For example, provide medication calendars, pill cards, or schedules that specify when and how to take medications.

Finally, we need to encourage our organizations and government to consider unintended consequences before enacting legislation. A few years ago, capitation was considered a method to control costs. (Gosfield, A. G. (2022). Pitfalls to Avoid in Physician Compensation Models. Family Practice Management, 29(5), 23-28.) However, this approach to cost containment led to patient and physician rebellion. The financial incentives built into capitation model led HMOs to ration care and accuse insurance companies of putting profits before patients' health. This unintended consequence might have been avoided if insurance companies included physicians' and patients' opinions regarding the downside of capitation.

Bottom Line

Unintended consequences are an inherent part of medicine in clinical practice and non-clinical decision-making. As physicians, it is essential to be aware of these potential consequences and take steps to mitigate their impact on patient care and the healthcare system. By embracing a patient-centered approach and fostering a culture of continuous learning and collaboration, we can mitigate the complexities of unintended consequences and provide the best possible care to our patients. Failure to consider unintended consequences might result in another thalidomide crisis.

Neil Baum, MD, a Professor of Clinical Urology at Tulane University in New Orleans, LA. Dr. Baum is the author of several books, including the best-selling book, Marketing Your Medical Practice-Ethically, Effectively, and Economically, which has sold over 225,000 copies and has been translated into Spanish.