The Cascade Effect in Clinical Care of Patients
https://www.nejm.org/doi/full/10.1056/NEJM198602203140809
The cascade effect, a chain of events that tends to proceed with increasing momentum, also occurs pretty common in the clinical care of patients. The participants in the process are often unaware that it is a cascade effect, and they frequently fail to recognize its cause.
A 59-year-old man was admitted to the surgical service of the University Medical Center for elective repair of an inguinal hernia. Throughout the process, the patient experienced more and more anxiety and discomfort as a result of concerning about his own medical history, complicated examination process, and long wait in between. The physicians taking care of this patient felt powerless to stop what seemed to be a succession of problems. The fact that this patient entered the hospital in stable condition, and it’s unlikely that his condition became unstable enough to require the testing and interventions that he eventually received.
The article then talked about the danger of a cascade, which is that a cascade can be easily, inappropriately trigger, and once it’s triggered, it’s almost impossible to stop. Factors that can trigger a cascade in clinical patient care includes: incomplete or inaccurate data base, error in data analysis, underestimation of the risks of evaluation or treatment, and unwillingness on the part of the physician to risk a bad outcome. The cascade effect is by no means uncommon in clinical medicine. When physicians fail to understand this, they are in danger of underestimating the effect of small commissions, omissions, miscalculations, or errors of judgment. The following principles, if understood and practiced, may help to avoid these problems.
- Taking an accurate history by obtaining data from family members, previous physicians, and old hospital records as well as from the usual patient interview.
- Any finding on physical examination or laboratory testing should be evaluated in the light of its predictive value (specificity and sensitivity of the test).
- Tests should be ordered with a specific goal in mind. It is vital to remember that the adverse effects of a test or procedure include not only allergic reactions, the discomfort of injections, and cost, but also such risks as increased anxiety and false positive results.
- Perhaps most important, we need to remember that certain risks may be unavoidable. There are always going to be some bad outcomes, and we cannot subject every patient to aggressive testing and monitoring simply to avoid some very uncommon bad consequences in a few.