This week newspapers reported assorted medical specialty societies are recommending doctors perform fewer tests and procedures. They also urged patients to question the value of these services, if offered.
Some of the over-ordered tests:
- Routine EKG at routine physical
- MRI for recent back pain
- Imaging studies for patient suffering from simple headaches
- Antibiotics for sinusitis.
Two points:
“These all sound reasonable, but don’t forget that every person you’re looking after is unique,” said Dr. Eric Topol, chief academic officer of Scripps Health, a health system based in San Diego, adding that he worried that the group’s advice would make tailoring care to individual patients harder. “This kind of one-size-fits-all approach can be a real detriment to good care.”
Next, the N.Y. Times opined: “Clear, evidence-based guidelines like the ones to be issued Wednesday will go far both to reassure physicians and to shield them from litigation.”
Really? How will evidence-based guidelines shield doctors from baseless litigation? Many such guidelines already exist. It requires little more than one plaintiff’s expert to argue the guidelines did not apply in this unique case. Unless and until such guidelines can serve as explicit exculpatory evidence in court (codified in statute), it will be challenging to get enthusiastic buy-in from doctors.
Finally, often it’s the patient demanding an MR study for three days of uncomplicated back pain. It’s rarely the doctor. So, patients’ expectations will need to be adjusted. This will likely take more effort and education than a simple declaration from organized medicine.
There are 5 reasons doctors order tests or treatments.
Two are valid/good reasons to do testing:
-To inform the decision-making for a patient one is treating
-To inform the decision-making by anther doctor who will soon be evaluating the patient
Three bad reasons include:
-For perceived or real medicolegal protection
-To make it appear that a higher level of service was needed to provide care
-To mollify a patient
There have been numerous attempts to quantify the costs of our medicolegal system, and the estimates vary, depending on the methods used.
However, I wonder if there has been a realistic quantification of the incremental costs of tests ordered just to keep the patient “satisfied” despite the lack of a good medical indication…for instance, CT head after minor head trauma in children, etc etc.
It sounds very good for medical societies to state their feelings that there are too many test been ordered on patients. However they have failed to state emphatically that medicine is an inexact science, and therefore it will be unethical to use a one size fit all approach to determine what is best for each patient without an actual evaluation by the person making such determination as to what test is needed to confirm a diagnosis. It is very unfortunate that there are various societies, medical establishment and state medical boards whose primary function is to past judgement on decisions made by treating physicians who has examine the patient without having the first hand examination of said patient as the treating physician. These people gives medicine a bad name yet sometimes the standard of care is based on their edict. The danger of one size fit all
Great idea…but in today’s society…UNTIL there are some serious changes in lawsuits, there is no way any doctor should feel comfortable not ordering any diagnostic tests associated with a new patients symptoms. Is our doctor able to “call ” it correctly 98 % of the time after taking a complete history and examining the patient ? Of course he can….it’s the 2 % he may miss something that will cost him three to five years of his life in litigation. Tread careful before you decide to “skip” the MRI when a new patient steps in your office with and I quote “This is the worst headache I’ve ever had.” Hundreds of patients say this very same thing. One out of a hundred patients that say this to their neurologist may have an aneurysm.
That will cost you …dearly…. It is a fact…defensive medicine costs are ridiculously high and a terrible waste. Now what?
Instead of reducing testing which actually may be needed and beneficial in certain cases, maybe we should stop spending untold billions with futile ICU care for patients who have no chance of survival. These guidelines will only further erode the quality of our medical system.
Signed by board certified primary care MD
They can come up with all the guidelines they want. Until I’m guaranteed that I’m not going to get drug through the mud if I follow the guideline, it might as well not exist. I overorder labs on neonates, and I admit it; the reason is because heaven forbid a baby born to a GBS+ mother who received antibiotics 45 minutes before the C-section get septic.
Now that the payors want to base reimbursement on “patient satisfaction” metrics, do you honestly think that I’m going to argue with the patient that he doesn’t need an MRI? Hell no. That is going to result in more tests ordered, if for nothing else than to make the patient think that you’re “doing something.”
For forums that don’t examine patients telling physicians (sorry, but we are not providers) what not to order for an examined symptomatic patient is ridiculous. Physicians do not have the luxury of claiming “preponderance of evidence” or “beyond reasonable doubt” in a litigation that will follow when a test is not ordered yet the problem later is found. In this society no statistical data and no guidelines based on them, rational as they may be, will ever save you from being sued.
The article quoted that specialists order more testing then necessary. Our biggest problem is our referral process. Most specialists that know do not require referrals for the specialist to see the patient. For example I run a pain clinic all patients need referrals that is no self referrals or walk ins. That way the primary care physician has seen the patient and has started NSAIDs physical therapy and or ordered a scan. That way if I need to order a test if I am not sure as to the diagnosis it is typically very appropriate. I believe the reason most specialists do not require referrals is that it increases their patient load that is their income. If the patient with back pain, headache , Or a sinus infection would see his /her PCP first then I believe they would be a lot less need for the patient to see a specialist hence, less testing and more appropriate testing.
When I started in medicine many decades ago the way to a diagnosis was history and physical exam. Diagnoses are missed when a good H&P is not done and testing is never a substitute. One should always know what one is looking for and what one will do with the results when ordering tests. Guidelines give us a framework for evaluation and decision making using medical evidence. Patients must always be evaluated and treated as individuals. The way to deal with unreasonable demands for testing is to educate the patient and remind them that they are paying us for our knowledge and skill. I saw a patient with back pain who was told by another physician that she needed an MRI. It took only a good H&P to make a diagnosis of fibromyalgia, something an MRI cannot do. Yes, Yes, Yes, patient needs to start with PCP. Specialists think only of their area of medicine. PCP thinks more globally.