Understanding the Over-testing Culture
Eric Glazer
Vice President
Physician Engagement and Social Media
Best Doctors, Inc.
At the recent Diagnostic Error in Medicine Conference (DEM, held at Johns Hopkins, Nov. 11-15), Dr. Jodi Segal summarized the problem of the overuse of diagnostic tests frankly, “If a test doesn’t influence decisions, it’s a waste.”
That may sound like a sweeping statement, but with reports indicating that the healthcare system spends $750 billion a year in avoidable costs, perhaps it’s an ethos the system should consider adopting. Unnecessary testing doesn’t just burden a healthcare system already saddled with prohibitive costs, but can deny a timely resolution of an accurate diagnosis, causing real harm to the patients who most need care.
Changing any system starts with understanding the “whys.” It can’t be assumed that the majority of doctors endorse a system of waste and inefficiency, nor are they ignorant of it. The real reasons the practice of unnecessary testing persists reflect that most doctors are not perpetuating the system, but mired in it.
It’s generally assumed that the “CYA” strategy is the largest contributor to the over-testing problem. And really, it’s a fair assumption. A litigious patient is a scary prospect for a doctor, and a thick paper trail of tests makes many feel they have insured themselves against a lawsuit, should their competence in handling a case ever come into question.
As Dr. Adam Finkelstein, Director of Interventional Oncology at Swedish Covenant Hospital, noted in a previous post, patients often view medical tests as a more thorough level of care, proof that their physician is carefully considering their problem. In the age of the epatient, the “engaged” are not always the “educated,” meaning the results of a test a patient requests may have little to no real bearing on their diagnosis or treatment. It’s important for physicians and patients to partner in managing care, with physician encouraging a healthy culture of question-asking and shared decision making.
Even those doctors who wish to change the culture of wasteful testing acknowledge that they are paid (and sometimes quite handsomely) for every test they order. There is no data on the average percentage of income this generates for physicians, and one doesn’t like to assume that any doctor would order an unnecessary test purely for the money, but the fact remains that the extra income is probably appreciated, and not all are enthusiastic to part with it.
Even patients are aware that doctors are notoriously strapped for time. What they might not know is that doctors often find it quicker to order a battery of tests than to talk to a patient or pore over a case to find the cause of the symptoms.
The US is famous for a medical community which can supply every detailed test, latest technology or obscure procedure a patient might require: a praiseworthy reputation by any standard. But easy access to a litany of tests has lead to their rote ordering, diluting the pinpoint accuracy that a more focused approach would yield.
Brian Jackson, MD, MS added a great point to this discussion recently DEM, “When you build lots of cancer screening into the system, you get what you ask for: lots of screening, regardless of whether it’s useful.”
Perhaps, as Paul Epner, MPH, MEd suggested at DEM, the test-reduction movement should focus less on what is going wrong in the system, and more on the development of tools and procedures to help things go right. By shifting the conversation to focus on the appropriate use of tests, the system can develop a framework of steps, algorithms and check-points which will make ordering of appropriate tests the standard operating procedure.
And when in doubt, suggests Dr. Finkelstein, don’t hesitate to consult with a specialist colleague. “If the treating physician would only call my radiology lab and ask me whether a test will be useful, I’d be more than happy to speak to them about their patient.”
Changing this system is a goal physicians can only reach by communicating and working together.
Don’t miss our videocast of a Physician Panel: Linking Inappropriate Testing and Diagnostic Accuracy. Click here to request a copy of the recording.
