BLOG: Dismantling Dogma - Part 1

𝗗𝗼𝗴𝗺𝗮 #𝟭 - “𝗟𝗲𝘀𝘀 𝗶𝘀 𝗠𝗼𝗿𝗲”

I'm launching a short series examining clinical dogmas - widely accepted phrases and practices that began as valuable principles but have calcified into automatic responses. When unchallenged, these reflexes can cloud clinical judgment and harm patients.

𝘈 𝘯𝘰𝘵𝘦 𝘶𝘱𝘧𝘳𝘰𝘯𝘵: These phrases gained popularity for good reason, and hearing them from your doctor often signals appropriate, thoughtful care. However, they unfortunately also tend to surface when our biases are active, making it easier to default to them without examination.

𝗧𝗵𝗲 𝗩𝗮𝗹𝘂𝗲
- "Less is more" recognizes that medical intervention doesn't always improve outcomes. This is important! Tolerating a difficult situation can often yield better results than intervening - as seen with low back surgery, unnecessary cardiac stents, and antibiotics for viral infections.
- This principle is especially vital in geriatric medicine, where interventions often carry higher risks than benefits, and the risk of iatrogenesis is relatively high.
- The movement interestingly dovetails with the current zeitgeist of value-based care and reducing unnecessary utilization (whether that be ED visits, hospital stays, diagnostics, or procedures)

𝗧𝗵𝗲 𝗧𝗿𝗮𝗽𝘀
“Less is More” falters mostly when the individual in front of us does not fit the risk profile of the “average” patient or when the circumstances lead us to either underappreciate the risk of inaction or disproportionately fear the risk of action.

Individualized cancer surveillance
- Population-based guidelines may not fit individuals with longer life expectancy or higher risk profiles. These patients can benefit from extended or earlier screening and deserve a thoughtful conversation.

High risk, higher reward
- A geriatric patient with symptomatic valve disease may gain substantial quality-of-life benefits from procedures like TAVR (a minimally invasive valve-replacement), despite age.

Prevention
- Long-term risks are harder to grasp, leading all of us to undervalue today's preventive actions. For a young patient with a high-risk profile (i.e. family history of early heart attacks), aggressive prevention may be quite important!

Our own discomfort
- Appallingly, we have misused "less is more" to deny perimenopausal women hormone replacement therapy, perpetuating a terrible legacy.

Whether you're a clinician or patient, every health decision deserves careful, individualized consideration - a balancing of rules and reality.