The unintended consequences of well meaning regulation

Why do we never consider unintended consequences? Whether we are thinking of legislation or physician led guideline panels, or governing bodies (like ACGME), the lack of consideration of unintended consequences remains mind numbing.

Let me provide some examples.

Please read this articles about how the war on drugs has fueled the hepatitis C epidemic. One could also argue that this war damages more young people than the drugs themselves.

Many illicit drugs do damage to users. But the laws impact both the users and innocent bystanders. The laws put too many young adults in prison. The laws force a black market, and for many drugs stimulate crime. Advocating for de-criminalization is not advocating for drug use, but rather focusing on preventing complications (like infections) and on programs to help patients stop drug use.

Next read any number of blog posts on performance measures. Let me give 3 quick examples of poorly considered performance measures.

The most obvious is the 4-hour pneumonia rule that led to increased unnecessary antibiotic usage. Trying to drive HgbA1c below 7% for every patient puts some patients at risk from hypoglycemia and from drug side effects. In Great Britain, paying physicians to decrease appointment waiting time induced less continuity of care (with the primary physician).

Finally, we are learning what many predicted. The work hour restrictions for residents are hampering medical education: For New Doctors, 8 Minutes Per Patient.

In example after example, thoughtful critics receive minimal lip service. Each group of decision makers moved forward, damn the torpedoes, full speed ahead.


I believe that the big problem is the affect heuristic. In short, that decision making heuristic says that if you like an idea, you over value the benefits, and underestimate the harms. We must figure out how to work around this undervalued concept. We desperately need to develop decision making processes that focus on both benefits and harms and develop logical means for balancing the benefits and harms.

Unfortunately, I remain pessimistic. Decision making bodies have biases. Until they understand their biases, we will have the problem of unfortunate, unnecessary and potential dangerous unintended consequences.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • Anthony D

    If you can use Google and do some basic research you will find out for yourself just how bad it is and come January 01 just how much worse it is going to get. But to get you started, a 2700 page bill backed by 13,000 pages – and climbing – cannot be good. Add in the IRS who is going to be handling the enforcement of ObamaCare….what could possibly go wrong!

  • buzzkillerjsmith

    To answer your question, unintended consequences are not adequately taken into account because the persons who cause these consequences are often not the persons who have to deal with them.

    • southerndoc1

      Locus classicus: the interview with Farzad Mostashari on the AAFP web site

      • buzzkillerjsmith

        There is joy to be derived from wielding arbitrary power. Anyone who has had a younger sibling knows this.

        But docs, especially the high-volume low-margin primary care docs who are most-affected by this technophilia and other similar projects, live in great hope that the stock market continues to rise. And the medical students are simply aghast.

  • Margalit Gur-Arie

    I actually think it’s way simpler than that. The people who make decisions have no understanding of how things actually work. They just perpetually move happily and blissfully towards the next shiny thing….

  • Alice Robertson

    I think you are talking about the “Greater Good” which is used with immunizations (where doctors are using legislation to force parents into something that science can’t sell them on…or to let them know they are incapable of a good decision so we will just make that decision for them).

    The problem is that, indeed, ideas do have consequences, but so much of what is done in medicine is pushed by doctors themselves under all sorts of guises. Sadly it’s your colleagues who then proceed to let the rest of us know just how ignorant we are and that we need to trust them. It happens in the FDA and CDC (where a type of modus operandi deceives us into thinking we, the people. are the reason they exist. At times we do seem to win, but overall it appears many have their eyes on their own future careers and stock options for their future job prospects) it happens in hospitals (often with doctors at the realm) and with legislators who rely on what is often bad science that leads to bad decisions because someone or a group of people see a way to gain an advantage…and again it’s often doctors.

    We can vote legislators out, but those doc consulting and investing are often a problematic bunch:) They hurt the ability of good doctors to do their job.

  • azmd

    Let’s not also forget that we have a very strong “no whining” culture in medicine. This is a useful habit of mind to cultivate, for example, when you are being awakened at 3 am to take care of a sick patient.

    It is less useful, and in my opinion, somewhat toxic, when our proscriptions against “whining” are used to silence those who are pointing out that an administrative decision will have adverse consequences on patient care, or physician efficiency.

    I suspect that it’s the “no whining” mandate that’s at work when primary care physicians don’t speak up about being expected to do 22 hours worth of work per day for an annual salary that qualifies their children for financial aid at top-tier colleges (assuming they can get in, since a family’s finances are increasingly a determining factor for college admissions these days).

    The problem with not allowing people to speak up is this: silencing their objections is not the same thing as getting them not to object. They will object in different ways, by electing not to go into primary care, for example, by not accepting Medicare, or by passive noncooperation with regulations they perceive as counterproductive. And once you have a large group of people silently objecting to decisions that are being made about their work, you have a dysfunctional working system. Sound familiar?

  • C.L.J. Murphy

    From Reason Magazine, “Pathological Altruism: The Road to Hell Really Is Often Paved With Good Intentions”:

    In a remarkably interesting new paper, “Concepts and implications of altruism bias and pathological altruism,” in the Proceedings of the National Academy of Sciences, Oakland University systems engineer Barbara Oakley argues that intentions to help people all too often hurt them.

    Unintended harm is the outcome of she what calls pathological altruism.

    http: //reason. com/blog/2013/06/19/pathological-altruism-the-road-to-hell-r

    - Milton Friedman wrote that “It’s poor judgement to judge programs on intentions rather than outcomes.” But we keep doing it anyway.

  • darbsnave

    There are a lot of reasons for unintended consequences. Suppose you are on a Board of Directors and decide that big is good. You will pay the CEO based on the size of the company. Then, the guy goes on an acquisition binge that wrecks or nearly wrecks the company. What you as a Board did is substitute “big” for “good.”

    A similar thing can happen if you decide to publish report cards on physicians. What might happen is that the doctors will try to get A’s on the report cards. If the goal, better patient care, is well aligned with the measurement, the report cards, you might get a good result. If they are not well aligned, you will get an unintended consequence.

    The guy who (as far as I know) first wrote about this is Robert Merton, the sociologist. He called it “goal displacement”-you’ve taken the measurement as the goal, rather than the goal itself.

    There’s a similar concept which says that using any measurement in a policy means that the measurement ceases to have any value. It is variously known as Campbell’s Law, Lucas Critique, Goodhart’s Law. It is highly humorous, but there are academic studies that reportedly show that these laws are not always true, and in fact may never be true.

    • C.L.J. Murphy

      There’s the apocryphal anecdote about State window-glass factories under the Soviets. It goes like this:

      “In the former Soviet Union, managers and employees of State glass plants were at one time rewarded according to the tons of sheet glass produced. This resulted in very thick glass windows that distorted images as people tried to peer through them.

      “The rules were changed so that the managers were rewarded according to the square meters of glass produced. The results were predictable. Under the new rules, the result was very thin glass windows, so brittle that many cracked/broke while in transit to construction sites.”

      And so it goes.

  • meyati

    Our society kicks out the “Devil’s advocates” that points out possible flaws and ill consequences. So we don’t seem to have dissenters on boards and committees to help find out why things might not work, so a suitable plan can be implemented. I think that school has had too many group projects, let’s play together well. This is the result. Thomas Edison, Johannes Kepler, Galileo, Copernicus, Count Wallenberg, Gen. Patton, Einstein, Bill Gates all thought out of the box, because they were independent thinkers.

  • Kobukvolbane

    Residents have less time with patients because hospitals want to get as much work out of them as possible. Hospitals could change this. For residents, teaching and learning should be first. They shouldn’t be indentured servants.

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