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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Pat Conrad MD

Pat Conrad is a full-time rural ER doc on the Florida Gulf Coast. After serving as a carrier naval flight officer, he graduated from the University of Florida College of Medicine, and the Tallahassee Family Medicine residency program. His commentary has appeared in Medical Economics and at AuthenticMedicine.com . Conrad’s work stresses individual freedom and autonomy as the crucial foundation for medical excellence, is wary of all collective solutions, and recognizes that the vast majority of poisonous snakebites are concurrent with alcohol consumption. 

  5 comments for “Do You Order Too Many Tests?

  1. James Tinsley
    May 12, 2019 at 12:54 pm

    The problem is with 10 minute visits we don’t really know these patients and they don’t know us. So they can sue us for anything and are more likely to for a bad diagnosis. My one and only lawsuit was dropped like a bad habbit. I saw him one time, ordered routine labs iaw guidelines, he blew me off and didn’t get them. Came back later sicker and saw my PA and got the labs, diagnosed with cancer. Family sued because I didn’t give a diagnosis after my visit. People who know you are much less likely to sue. I work part-time in a Medicaid clinic. Lots of self pays who have to pay for their labs. I am a much better steward with their money and discuss the labs and cost with them. They share in the decision making. it’s their money. I order the more expensive tests if necessary later and they happily agree.

  2. Steve O'
    May 11, 2019 at 10:07 am

    My wife and I played a little game. She read the book Fascinomas by Clifton Meador MD. He’s a great writer for docs who wish to learn how to practice with insight. She offered to read me samples of the individual stories, offered as medical mysteries.
    Most of the “mystery” side came from modern inadequacy; insufficient history, inadequate examination, rarely from insufficient testing.
    The “regulators” have the cart before the horse. The least expensive test known to medicine is a qualified physician at bedside. They’re already through the investment phase, and the cost is pennies on the dollar. A number of the “Fascinomas” could have been picked up solely through prudent testing, rather than just the history and physical, if one is pressed for time.
    It’s a shame that American quality medical practice is vanishing into the Dark Ages. Something that’s not practiced in one generation, is unknown to the next; and unimaginable to the ones thereafter. Modern residents are lost in the Dark Ages of medicine. In twenty years, much knowledge will vanish – something that the techno’s don’t understand. You can put Google Glasses on an experienced surgeon, but you won’t get an experienced surgeon, silicon-style.
    I was extremely sad after hearing the story of one high-school football player. He hurt his lower leg while practicing, and it was excruciating. Just that much information got me thinking about plantaris tendon rupture, or perhaps compartment syndrome. I have seen both.
    The distraught parents brought the kid to three ER’s within 24 hours, and left with the diagnosis of “normal exam, drug-seeking.” This is not the fault of technology, but intellectual dullness. The examination for compartment syndrome takes perhaps ten seconds, and the pearl is “POOP(PPP)” – pain out of proportion to physical examination (passive pushing and pulling.) Passively plantarflex the foot, and the kid looks like a scene in the Exorcist, and voila, call the surgeon. That was not considered or tested in three ER visits. The kid wound up with a permanent foot drop and an AFO.
    I just wanted to scream. A competent history takes at most five minutes; a competent examination, another minute. Necessary testing? None.
    I’m not SuperDoc – I’ve just seen this before. What you need is sufficient BEDSIDE training so people recognize things. Dr. Watson and robo-diagnosis will never get it.
    That kid’s permanent foot drop is a concrete consequence of the reckless disregard for the damage to American medicine brought on over 20-some years. And a doctor in a decent hospital ER in Guatemala City wouldn’t have missed this diagnosis. It’s a tragedy.

  3. May 11, 2019 at 7:54 am

    Good article. I consider guidelines to be merely considerations. What might need consideration in evaluating this patient? They are a decision aid which might be a helpful reminder at times and an annoying nuisance at others (e.g., statins for everyone who breathes). PA’s and NP’s may actually have to use guidelines as if they are laws or sacred truths, which costs a lot. Physicians aren’t trapped by guidelines, but sadly, many folks don’t understand that.

    • Steve O'
      May 11, 2019 at 10:54 am

      I usually avoid anything to do with medical education like the plague. (However, the plague can be treated and cured; medical education is too far gone.)
      My exception involves the benign torment of fellows in specialties on consults; which I relish. One of my favorite recent tricks was to send the Rheumatology fellow a consult: “Psoriatic arthritis sin psoriasis. Confirm, treat.”
      (That is, psoriatic arthritis; but there’s no psoriasis to be found on the patient.) It’s an arcane diagnosis. No labs are necessary, radiographs can be helpful; but a history and examination can confirm the presence of PsoA, and the absence of psoriasis. A good fellow will send back a detailed H&P, films and appropriate labs, discuss the diagnosis and treatment plans, with a bit of a querulous undertone.
      Several of the fellows in various subspecialties seem to actively avoid me; I suspect they think I have fey powers and keep a dowsing rod in my office, and my diagnostic manual in a dybbuk box. The teaching point is, you need labs only when you need labs.

  4. Sir Lance-a-lot
    May 11, 2019 at 7:07 am

    I’m right there with you, Pat.

    I’m probably in the very lowest part of the “tests ordered” curve compared to my colleagues at work, as I actually try to figure out what’s going on (silly me), but I still over-order things like ankle and knee X-rays by a factor of about ten. Why? Because, in the end, it’s what the patient wants. They twisted their ankle, and they want an X-ray, not a ten minute lecture about the Ottawa criteria.
    I X-ray, I have a fast, pleasant visit, everyone’s happy.
    I don’t X-ray, I have a grumbling patient, a long visit, and possibly a patient complaint.

    There is value in the placebo, and there is value in radiotherapy for the patient’s peace of mind, which is the reason the patient came in in the first place. And maybe one day I’ll find a Ewing’s or something…

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