Do You Order Too Many Tests?

Do you order too many tests? A lot of doctors are told we do, for various reasons, and every one of us knows the expected talking points when asked:  too many tests lead to incidental findings that then require more testing, often invasive, which leads to bad and arguably avoidable consequences.  We all know that over-testing leads to bigger bills, and makes us bad stewards of dwindling resources in the eyes of Big Insurance, the government, academia, and the chin-tucking media (not coincidentally all parties that should be utterly despised).  Over-testing costs more time, money, angst, and can set off chain reactions that ruin patient’s lives.

A NPR piece tells us that its largely due to training, and a residency culture of testing for every possible entry on the differential diagnosis list before the attending chews your ass on morning rounds for being incomplete.  This article quotes a study claiming we could reduce medical testing/interventions with no decrease in care quality.  

My DPC physician and I discussed this, both agreeing that unneeded testing can lead turn boogeymen into very real monsters.  And yet, I flagrantly violate the deductive method I was taught in residency every day I work in the ED, “shotgunning” testing orders based solely on the chief complaint, because 1) I’m going to order the same set of tests every time a middle-aged adult says “short of breath” and, 2) there is a certain lag time that ordering up front helps to minimize. Clinics, urgent care centers, and ED’s all have to consider wait times and throughput, and this is the realistic way to set tempo.  

This article uses the word “guidelines,” to which I have a gut inversion.  While rules are objective and simple (if often stupid), guidelines are subjective and function to ensure that the physician is always at fault.  Don’t follow CMS guidelines working up an elderly altered mental status case, and the hospital will not get paid; do follow them, and you will often order stuff that you did not believe was clinically warranted.  Either way, the system is ready to presume the doctor either spent too much money, or did not provide “quality” care (by the definition of the week). 

This article describes how academicians are developing databases to allow residents to compare their individual rates of ordering broad-spectrum antibiotics, extensive imagery, or recommending invasive procedures to those of their peers.  A Johns Hopkins radiologist associate professor “says she and her colleagues give out personalized reports that show how individual doctors compare to their peers. She’s currently studying whether these reports are effective in reducing the number of CT scans ordered to check for blood clots in the lungs. ‘There are clear guidelines for when a CT scan is the right test to check for clots,’ she says, ‘but they’re often ignored, in part, because doctors are afraid of missing a life-threatening diagnosis. 

The best way to avoid a diagnostic error is to avoid an unnecessary test.'”  The academicians seek to harness the “competitive spirit” in residents who they suggest will want to be in the top percentiles for ordering only the right diagnostics and therapeutics.  And in a sane world that valued the nobility of reason and trusting relationships, I would applaud their mindset.

But this is not that world. Big Insurance exists to not pay doctors for work already honestly done.  Big Government assumes that all doctors are fraudulent serfs, else they would not treat us as they do.  If they reward doctors who do less, then do we really believe that results in better patient care?  Capitation, anyone?

The sad truth is that Big Insurance, Big Government, and academia all seek to subordinate, even substitute individual reasoned judgment with collective solutions, which by their very nature are subject to politics, fashion, emotion, and good ol’ greed. Call me a cynic, but I don’t think any of the parties mentioned above really gives a damn whether the physician really renders the best care according to his own expertise and judgment.

Oh, I’m sorry, we forgot to mention the most important group of all:  patients.  What of the patients?  Don’t they deserve our best efforts no matter what the collective orders, and don’t they have a say?  

I respectfully disagree with my esteemed radiology colleague noted above.  Over-testing may or may not lead to diagnostic errors, but under-testing – in the context of a bad outcome – leads to a malpractice lawsuit.

And nowhere in the article could I find the term “lawyers.”

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