The work of a physician to make the correct diagnosis for a patient is often quite challenging. Few tests are truly “gold standard” tests, which tell if a patient has a disease or she does not. Most tests are not gold standard tests; they are imperfect, so when the doctor gets the result, the probability that the patient has the disease under question goes up or goes down but the physician is still not sure.
Before ordering a test, the doctor needs to ask himself or herself: “What will I do with the result?” If the result is not going to change the treatment, then why order the test? Physicians are concerned about not doing the right thing by the patient. There are also some patients who believe that “more” is always better. This is clearly not true since tests that are not gold standard tests may lead the physician and patient to do something that might actually harm the patient.
Have you ever questioned why you or a family member were getting a particular medical test because you wondered how it was going to help? Or are you the type of patient who urges your doctor to do every possible test and procedure under the belief that more is always better?
There have been many studies throughout the years documenting that many patients are having tests where the evidence says that they will not benefit from having it done. The conversation about “overtesting” has often quickly turned to a discussion of the fear of being sued for not doing a test and it has stopped there. But now, probably because in our country we can no longer afford to deliver care that doesn’t actually lead to better outcomes, the pendulum is swaying in the other direction, toward eliminating testing that might do more harm than good to both the patient and the community.
Recently, nine major medical specialty groups identified 45 common procedures and tests that they recommend eliminating from routine patient care because they are often not needed, duplicative, wasteful, or can potentially harm the patient. These professional societies, which collectively have 375,000 physician members, are: The American Academy of Allergy, Asthma & Immunology; The American Academy of Family Physicians; The American College of Cardiology; The American College of Physicians; The American College of Radiology; The American Gastroenterological Association; The American Society of Clinical Oncology; The American Society of Nephrology; and The American Society of Nuclear Cardiology.
The entire list of 45 often unnecessary diagnostic tests and therapeutic procedures that don’t actually lead to better health for the patient is available online at http://choosingwisely.org/?page_id=13
(you have to click on the name of each of the 9 societies to see that society's list of 5).
I’m very pleased to see this happening, because I have been upset for years that doctors, even some who I have great respect for, have said, “I know that (procedure X) isn’t going to help the patient, but they demanded it so I did it.” I don’t accept that. I believe that we doctors, by not acting according to the evidence, have sometimes led patients to the position they are in, where they believe that more is always better.
The Society for Medical Decision Making was founded more than 25 years ago by a group of doctors who believed there was both an art and a science to medicine, but that these two were frequently confused. The art is about the relationship between the physician and the patient and knowing how to approach each individual patient and what guidance he or she may need. Knowing what tests to order is a science. Oftentimes hard evidence exists about whether to do a test or not but it is invisible to the physician or it is ignored. The physician must have the evidence about the expected benefit of the proposed test in hand and he or she must discuss this with the patient to help him or her make an informed decision.
For example, the evidence is clear that many patients with an ankle injury do not benefit from an X-ray. In addition to the cost, they get unnecessary radiation and a longer stay in the ED. There’s a set of questions called the Ottawa Ankle Rules http://www.ohri.ca/emerg/cdr/ankle.html that is 100 percent sensitive for ankle fractures. Therefore it is a gold standard test. If the answer is “no” to all five questions, the patient does not need an x-ray and should be sent home with an ankle wrap, pain medication and instructions to rest the ankle. But when a patient walks into many emergency departments in the country with an ankle injury often the first thing they are going to get is an x-ray, with many of them being unnecessary.
We need to build a system that uses evidence-based test ordering to get to better health at lower costs.
What do you think about the reduction in potentially unnecessary medical tests?
Kudos to Hunt Manor Staff
Continuing with the “best practices” theme, kudos to the staff at our Hunt Manor practice, especially Chelsey Schaffer, a patient services assistant, and Kimberly West, a nurse practitioner. A Hunt Manor patient mentioned in a letter what a significant impact their smiles, compassion and caring meant when he came for an appointment recently and was severely depressed. “I left the exam room feeling that someone actually did care about me, and a total stranger! It made a world of difference to me.” That’s treating a patient the way we’d want our own loved ones to be treated. Nice job Chelsey and Kimberly!