On Tuesday, I shared the tragic story of how George Washington was "treated to death" by his trusted doctors. (I'll provide the link later if you need to catch up.) I also introduced you to a modern version of this nightmare: the "cascade of care."
To recap, a cascade happens when a doctor orders an unnecessary test and finds an unrelated "incidentaloma" (i.e., a harmless abnormality), only to trigger a never-ending barrage of follow-up visits, biopsies, and procedures that end up draining your wallet and even health.
What's more, cascades can happen in the place where the sickest of the sick come to be healed: the hospital.
A common problem, covered in two recent studies, involves overtreatment in the form of excessive monitoring...
For instance, a 2024 systematic review and meta-analysis of seven randomized controlled trials with 1,284 patients found that continuously checking vital signs in the general wards of hospitals (meaning, not intensive care units) failed to improve mortality rates compared with standard care.
And a 2025 study published in Neurology looked at 102,184 routine vital-sign checks from 5,569 non-ICU neurology patients. Researchers found that only 12% of those checks came up with something abnormal, with only 2.2% of checks taking place at night and needing urgent care.
For low-risk patients who had normal daytime vitals, it took 1,463 overnight checks to result in one urgent action.
Researchers concluded that this occasional benefit is outweighed by the harm to patients' sleep during recuperation. Put it this way, getting awoken every two hours for a blood-pressure check when you aren't in critical condition might actually end up keeping you sick.
So why does the system operate this way?
Why Cascades Happen
I've said it before, and I'll say it again: The medical industry is a business.
It mainly operates on a fee-for-service payment model. Whenever you visit a doctor's office, get a lab test, or undergo surgery, people are getting paid. When you stay home, they aren't. There's no financial incentive to give you less care.
Another scary reason for cascades is that your doctor might be Big Pharma's puppet... Thanks to the Open Payments federal program, patients can look up any doctor at openpaymentsdata.cms.gov to check for what kinds of payments they received from drugmakers. However, this spotlight means that some doctors can't just pocket cash payouts like they used to... Instead, they may get payoffs under the guise of speaking fees and free lunches.
Just a few years ago, five New York doctors were charged with accepting kickbacks for overprescribing an opioid from a company called Insys Therapeutics. Collectively, they raked in about $800,000... mainly in so-called "speaker fees" that ranged from sporting-event tickets to casino gambling sprees to even lap dances at a strip club.
Even well-intentioned doctors can spark a cascade of care. Your doctors may just want to do everything in their power to diagnose whatever is ailing you and to treat you. But they've undergone years of training to hunt for an answer, compelling them to keep going... ordering test after test to make a diagnosis.
Similarly, your doctor might be afraid of missing something that could end up hurting you.
Or a strong fear of a malpractice suit can lead to "defensive medicine." That's where doctors rattle off extra medical tests to cover all of their bases – sometimes 10 times over – with even unnecessary tests.
On the flip side, it might be the patient who demands unnecessary tests, and the doctor may just indulge the patient rather than following the medical evidence.
Five More Lines of Defense
On Tuesday, I shared the first five questions from the Choosing Wisely campaign. They're ones you should be asking your doctor before agreeing to any new test or treatment.
They were:
1. Do I really need this test?
2. What are the risks, including side effects, of getting the test?
3. Are there simpler, safer options like lifestyle changes I could try first instead?
4. What happens with my condition if I don't do anything?
5. How accurate is this test (including false positives and false negatives)?
To complete your defensive playbook, you need to ask your doctor point-blank if the test is known for throwing false positive results that will lead to invasive follow-up procedures down the line. You also need to make sure your doctor is ordering your test based on modern medical science and not just because "it's what I've always done for my patients."
I especially like asking your doctor what he or she would recommend if it were their loved one getting the test – it forces them to give an honest answer. And, of course, you should discuss matters of money and insurance coverage.
Here are the final five questions to add to your list:
6. What are the chances this might lead to more tests or procedures?
7. What do the latest evidence or clinical guidelines have to say about this test?
8. What would you recommend if it was your family member getting the test?
9. What's the cost, and are there less expensive options?
10. Will my insurance cover the test along with any follow-up care?
I suggest you write these questions down, leaving some room for you to jot down answers as you ask your doctor.
Please feel free to ask more, too... But these 10 questions will get you started as you and your doctor assess your care.
Never be afraid to pipe up and ask. Don't think that doing so makes you a "difficult" patient.
Rather, it makes you a smart consumer for your own health care.
If you find these strategies useful for advocating for your own health, you'll love what we're doing over at my flagship newsletter Retirement Millionaire – where we empower you on the financial side, too. Get the details on a trial subscription here.
What We're Reading...
- Did you miss it? When a doctor's good intentions kill.
- Something else: Man accidentally gains control of 7,000 robot vacuums.
Here's to our health, wealth, and a great retirement,
Dr. David Eifrig and the Health & Wealth Bulletin Research Team
February 26, 2026