Runaway Train

Introduction

Remember my 80-year-old patient who avoided doctors her whole life? Her family convinced her to visit the ER when she wasn't feeling well. They found red blood cells in her urine. No one knew how long they'd been there or what it meant. She went to radiology for a dye contrast study. She had a reaction to the dye. She spent months in our hospital as one complication followed another. Most came after tests.

She was the nicest lady. I often thought how different her final years would have been if she'd never come into the hospital.

Variations of this story unfold daily in exam rooms and hospitals across the country. This pattern has a name: the medical cascade.

A cascade doesn't start with a crisis. It begins with something routine.

Maybe an antibiotic triggers a reaction. Maybe a routine X-ray shows something suspicious. That triggers another study, then another.

Maybe the antibiotic clears the infection but wipes out gut flora. Diarrhea becomes bloating. They get another drug for the bloating. One drug follows another. Researchers call this a prescribing cascade.

Older adults suffer most from prescribing cascades. Many cardiovascular drugs initiate this pattern. Before you know it, they’re on multiple drugs to treat the side effects of other drugs.

Incidental findings on X-rays or scans can trigger cascades. A small nodule on chest xray is noted. A slight deviation from normal appears on a scan. In our litigious environment, providers leave no stone unturned.

Most physicians say chasing these findings add little clinical benefit. They still set off chains of follow-up testing, anxiety, and sometimes harm.

People demand specialists. The system's complexity creates these hazards. The problem worsens with aging patients. You think you're being thorough. Each step feels sensible at the time. The pattern reveals itself only in retrospect. The chain occurs from caution, not carelessness.

Here's a story from early in my emergency medicine career. Once I had to call an internist in the middle of the night to come and admit a patient. I quickly realized I'd triggered a cascade. In my effort to be thorough, I'd ordered extensive labs. I found abnormalities unrelated to the original complaint. I couldn't send them home with those results.

This is crude, but it stuck with me for 30 years. When I explained the situation to the internist arriving at 3 am to admit a patient, he said, "Barry, if you don't know what you're going to do with the booger, don't pick your nose."

Every test should have a plan for the result. Sometimes the right plan is to do nothing.

Why we can't stop

Most cascades begin with uncertainty. We can't accept it. We have to answer every finding. Imaging is often the trigger.

We perform 3.6 billion scans yearly. Half add little clinical value. The waste runs into billions of dollars. The deeper cost is what follows: more procedures, more anxiety, harm disguised as diligence.

We've created an epidemic out of numbers. We've had to find diagnoses to match them. Sometimes there's pressure to expand disease parameters to include more people. Expanding obesity diagnoses may help more people qualify for expensive GLP-1s and similar drugs. Always follow the dollars first if you’re puzzled as to the reason for a change that is curious. Do we have more obesity than the epidemic numbers we know about? Is there another reason to include more people in those stats.

Once there's a label, medicine acts.

U.S. physicians are compensated by volume of services, not outcomes. Money isn't the only driver. Our system is reactive. Physicians feel they must do something when waiting would be better. Patients judge their level of care by the quantity of test results.

Doctors want to help. Patients expect action. We get trapped in motion. Reassurance comes from another test, another scan. No one is content with conversation.

Most physicians have been drawn into cascades that began with unexpected results. The findings proved harmless. The process rarely stopped. Once a test reveals something, it's hard not to keep looking.

Patients navigate a system built on intervention.

Cascades rarely look reckless as they unfold. Each step feels reasonable, even careful. But when treatment changes direction, take notice.

When to step back

Are your symptoms resolved but you're still getting imaging or labs? Ask: "What problem are we monitoring, and what would change if we stopped?"

Labs look better but you don't feel better? Ask: "Are numbers driving my treatment, or is how I actually feel driving my treatment?"

Scan finds something "incidental"? You're told it's probably nothing, but another scan is ordered, then a specialist visit. Ask: "What are we hoping to find, and what would we do with that information?"

On more than five drugs? Ask: "Which drug can we taper first, and how will we know when that's safe?"

Dealing with medication side effects? One medication causes fatigue or dizziness. You get another drug for that side effect. Then another for the new side effects.

If after months of tests, referrals, or medications your plan feels disconnected from why you sought care in the first place, step back.

Ask: "What is the main goal of my treatment?"

Not all cascades are harmful. Some are necessary. Some are life-saving. Knowing when your care has drifted is the first step in regaining control.

This runs counter to how most of us think about health care. We're taught to repair, intervene, keep moving. But going slow is often better.

Slowing down isn't withholding care. It's not yielding to the reflex to act. The same tools that save lives can start chain reactions. There must be clear purpose. Knowing when to pause takes judgment and trust.