Why doctors order unnecessary tests

I’m happy that this study is getting some play in the media. Essentially, many of the “routine” tests done on a physical are not recommended (the whole concept of a “routine physical” is controversial – but that’s for another discussion). Merenstein concludes:

# 37 percent of checkups included a urinalysis.

# 9 percent of checkups included an electrocardiogram.

# 8 percent of checkups included an X-ray.

# 43 percent of checkups included at least one of these three tests.

None of these studies are recommended screening tests by the USPSTF. I have written previously about what routine tests should be done.

So, why are they being ordered? There are several reasons.

1) Blame the media

The mainstream media continues to push a “more testing equals better medicine” philosophy. High-profile malpractice cases often highlight missed diagnoses due to a failure to test.

Publications like this article from Forbes continues to push evidence-bereft screening tests:

Among the battery of screening tests you could talk to your doctor about getting: a lipid profile that includes a C-reactive protein measurement, a colonoscopy if you’re over 50 (or earlier if you’re at high risk for colorectal cancer), a diabetes risk test (fasting plasma glucose test or the oral glucose tolerance test), a stress test and a skin cancer exam.

There is no evidence to support a screening CRP, stress test or even skin cancer screening.

2) “Defensive medicine”

This blog’s favorite buzzword. It seems that Merenstein has taken up a crusade against unnecessary testing after being burned as a resident. Good for him.

I will not start another discussion about this topic and have the contrarian folks come back with how little data there is that defensive medicine exists/decreases lawsuits/lowers malpractice premiums etc. Instead, I will speak only for myself. If there were no-fault malpractice, health courts, or even caps (which I think is the least-effective solution), I would order less diagnostic tests. Period.

3) Reimbursement

Reimbursement in the US is essentially fee-for-service. Physicians get paid a set amount from an insurance company or Medicare/Medicaid for every service that they do. With reimbursements declining and overhead increasing, ordering more tests generates more revenue for a practice.

Of course, this is a ridiculous system for which there is no easy solution. Capitation was tried and failed miserably. Pay-for-performance is an untested answer. Increasing reimbursement may relieve some of the financial pressures physicians have to keep a practice afloat – subsequently decreasing the need for unnecessary testing.

As long as there is a fee for every service performed, there will continue to be an underlying financial incentive to order tests. That’s the simple reality – interpret that as you wish.

4) “Consumer-driven healthcare”

Another buzzword. There is a push for patients, I mean “healthcare consumers”, to shoulder a bigger financial responsibility for their health. With the media publicizing non-evidence-based testing (see point 1), consumers will have a greater say in what tests are ordered. It is their right after all – since they are paying for the tests. Besides, who wouldn’t like an executive physical? Expect this trend to increase.

There you have it. But before asking for that routine stress echo, chest x-ray, CA-125 test, or urinalysis, consider what you’re getting yourself into:

“The patient has no symptoms and doesn’t smoke, but he gets a routine chest X-ray. If there is a small shadow, doctors are obligated to look further.”

“That X-ray becomes a CT scan. That may show a small little nodule. The next thing you know, the patient ends up with a cardiothoracic surgeon who wants a needle biopsy, or even an open ,” he says. “In a lot of these cases, he comes up with nothing, a benign nodule or something.”

Aside from the costs in time and the potential for unnecessary suffering, these procedures add up to big money. Merenstein’s modest estimate of the cost of just these three simple tests is $47 million to $194 million a year. And that doesn’t include the cost of follow-up tests.

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  • ipanema

    Thanks for your insights on this issue Dr Kevin. As a patient I wonder why tests are being ordered and in the end, it has no bearing to my complaints at all. What a waste of time and money.

    I’m lucky though I have doctors who are confident in their initial findings and guide me through next stage.

  • diora

    I am surprised it is only 43% — less than half.
    You may add to your list of unnecessary testing pap smears for women who had hysterectomy done for non-cancer-related reasons. The women have no cervix yet their doctors continue testing them for cervical cancer! Is it defensive testing?
    Also pap smears for 70+ women who had no sex for years and had normal tests for 20+ years. BTW even though the guidelines say that for low-risk women with the history of normal pap smears the test can be done less often than once a year. Yet I haven’t yet encountered a doctor who follows this recommendation (including mine, my mother’s and all of my female friends). BTW – even patients who know about recommendations are often reluctant to bring the subject up with their doctors.

  • Anonymous

    At our large local clinic you can lose your PCP if you don’t make annual physicals (and it is increasingly difficult to find a primary care provider who accepts new patients). There’s some incentive to make appointments even if you’re feeling fine and dandy, just so you know you’ve got someone to go when when you’re actually sick. I don’t know if that’s an exception or the rule.

  • Anonymous

    Responding to “doria said”: Pap smears are done to detect cervical cancer and vaginal cancer (not just cervical cancer). Most cervical and vaginal cancer is now thought related to HPV. HPV may lie dormant for years. There is still need for Pap smears after hysterectomy because there is still a vagina and the female without a cervix is still at risk for vaginal cancer because of the HPV from a past or current partner. Given a patient with no risky partners (ever) the pap may not need be done yearly, but because HPV does lie dormant and may be undetected a pap ought be done say every 3 years in that case. Vaginal cancers include squamous cell cancer(these are the ones associated with HPV), adenocarcinoma (did your mother take DES?), malignant melanoma, and various sarcomas. Talk to your doctor for information specific to your situation.

  • Chris, RN

    Lung nodules are like colds. Once noted, the standard is f/u CT for 2 years. At approx $1,500 a pop, cha-ching, racking up the cost of “healthcare.”

  • Anonymous

    kevin, once again you see all medical policy issues thru the myopic prism of physician greed and vanity. The problem has nothing to do with defensive medicine or malpractice insurance. The problem is 3rd pary payer system. If consumers had to pay for these tests out-of-pocket, I’m sure they would conduct the proper cost/benefit analyses.

    Once again, doctors will never turn to solutions that empower their customers.

  • Anonymous

    anon 1003,

    Did doctors invent the third party payer system, or the expectation that the employer should provide health insurance? Did doctor invent the medicare/medicaid system? Please explain. We would love to do less tests. We would love to be able to demand same day payment at the time of service much like a plumber does.

    You are also myopic in not being able to comprehend. the cost of defensive medicine.

  • Anonymous

    “Increasing reimbursement may relieve some of the financial pressures physicians have to keep a practice afloat – subsequently decreasing the need for unnecessary testing.

    As long as there is a fee for every service performed, there will continue to be an underlying financial incentive to order tests. That’s the simple reality – interpret that as you wish.”

    Sorry, but that only makes sense if the doctor is also performing the test. That usually isn’t the case. Internists aren’t doing the MR or CT studies and aren’t being paid for those tests either. Even the routine chemistries are done elsewhere, unless they belong to a large multispecialty group that has a lab. Moneymaking isn’t a motive for testing, underlying or otherwise, anywhere I have ever practiced.

  • diora

    There is still need for Pap smears after hysterectomy because there is still a vagina and the female without a cervix is still at risk for vaginal cancer because of the HPV from a past or current partner.
    Not according to
    USPSTF
    . Same for older women. D recommendation for women who had hysterectomy and D recommendation for women over 65 with history of normal pap smears. And no my mother has never taken DES, but that’s beside the point. And by the way – just because a test can detect cancer doesn’t mean it improves survival nor that benefits outweight the risks. If you are aware of some studies that USPSTF missed, and I mean studies that show mortality reduction in these subgroups, feel free to provide links.

    As far as “talk to your doctor” is concerned – I wasn’t asking you a personal medical question or talking about my personal situation. I was making a generic comment about unnecessary testing. But since you mentioned “talking to your doctor” – is it a patient’s responsibility to read recommendations and learn that it might be OK to do the test every 3 years and then bring it up to the doctor, or shouldn’t doctors mention it to patients first?

  • Anonymous

    So, assuming everything Kevin says is true, what are physicians doing to change things?

  • Anonymous

    “So, assuming everything Kevin says is true, what are physicians doing to change things?”

    changing careers

  • joel topf

    When it mentions that these studies are unproven and unhelpful I wonder if their has been a large enough randomized study to determine it or just the absence of supporting data. It strikes me as unlikely that a urinalysis has been proven to be “harmful.”

    The absence of data is not the same data of absence and I bet most of this has not been proven to be helpful rather than have failed an adequitely powered study.

  • diora

    It strikes me as unlikely that a urinalysis has been proven to be “harmful.”
    I believe is what may be harmful are additional and more invasive tests they’ll send you if you get a false positive. Some of these tests may be sufficiently invasive to have risks of real harm. You may also get one of those “unable to rule out” ambiguous results and have months of more and more invasive tests and anxiety.

    But I am sure the doctors will correct me if I am wrong (as the anon at 9:26 attempted to do — I am still waiting for the references that would show USPSTF was wrong with its D recommendation, btw).

  • diora

    Just to add to my post above about urinalysis: here is info from the experts. Of course it is one thing to know about recommendation and quite another to call your doctor on it. I think somebody should teach us the right way to say “no, thanks” to a doctor when he gives you a referral with a bunch of tests written on them w/out any explanation why you need them.

  • Anonymous

    I think there is a difference between preventative testing and defensive testing Diora. I’m not sure how much of a risk is involved with a woman having a pap test? I’m sure someone can give us some number’s that have nothing to do with actual facts. The facts of pap tests are that since they were created, many womens lives have been saved. It is not an overly costly test and I think every woman should have them done.

    The exception might be older ladies who have never had a problem with them in the past. I’m not sure I understand where someone having a hyst. means they don’t need a pap test. You still have a vagina and cancer of the vagina is not unheard of.

    I think most women who don’t want a pap, avoid them because of comfort. It is not a pleasant test and even a little degrading and humiliating. But, I can take humiliation and a bit of discomfort alot better than I could take cancer. Imagine what one would have to endure if they didn’t have pap’s and then was diagnosed with invasive cancer?
    Such an inexpensive test with such little risk that women are fools to not have it done.

    If you had ever watched someone you care about die of cervical cancer (because she couldn’t be bothered with pap tests) you would schedule your test for tomorrow. It is a terribly painful death.

  • diora

    Anon at 11:15 – you have not read my posts. If you did you’d notice that I all for pap smears – I was specifically mentioning 3 things: 1) women who had hysterectomies for non-cancer related reasons (e.g. fibroids, endometriosis) and who have NO CERVIX – USPSTF recommends against pap smears yet doctors tests them 2) women older than 65, again USPSTF recommends against it and 3) frequency of testing, USPSTF says that for low-risk women who had at least 3 negative pap smears the test can safely be done less often than once a year e.g. once every three years yet doctors NEVER volunteer this information.

    As far as harms of testing is concerned – it is common to all tests: false positives that can lead to anxiety and to more tests. You can also get ambiguos results and be caught in an infinite cycle of testing. Also with 3 cases about cost.
    Can you show me any mortality reduction in 3 groups above?

    The subject is unnecessary testing and not necessarity defensive testing.

    Read what is posted before replying.

  • diora

    Just to add some info to my reply to anon at 1:11. I have already posted a link to USPSTF recommendations, so I am not going to repeat it.
    Here is the more detailed information about benefits and risks of pap smears. There are specific sections on harms that in addition to what I mention also incude treatment for early leisions that may never progress (and may even recede) but the treatment may affect fertility. But read for yourself. There are also specific sections about the evidence in three things that I mentioned in my previous post.

  • Anonymous

    As a physician, I was once sued for missing an extremely rare condition (I had her transfered to a teaching hospital and they missed it as well, but that is another story).
    Now everyone whom comes through my office is tested for this condition if they even remotely have a symptom that COULD be due to this condition. Number diagnosed in five years? zero.
    But I will not again be sued for missing it!!
    Also one asks, what are physicians doing to alter defensive medicine? alot just look at various web sites. Unfortunately lawyers control the government, not physicians. (Hmm perhaps that is why our governement is so screwed up). Lawyers do not listen to physicians, only voting patients.

  • Anonymous

    Diora, My only problem with your 3 issues are the “low risk women”. I don’t know what they are.

    Is it a woman who has never tested positive during a pap test? Thats all well and good, except then you ask women to make decisions based on their belief of other peoples behavior.

    I don’t have enough faith or trust in any other person alive to put my health totally in their hands.

    Men cheat all the time. Some even begin to do so after being married for 20-30 even 40 years. As a wife you usually do not get a report from a man when he begins an affair. They do not come home and say “Honey, I know you havent needed pap tests in the past, but I’am seeing another woman. since I’m fairly certain she was not a virgin you better start getting your paps done.”

    I only know for certain my own behavior, I’m making no guesses about anyone elses. Not even for loveeeee!

  • diora

    Diora, My only problem with your 3 issues are the “low risk women”. I don’t know what they are.

    Well low risk is indeed pretty broad – I should’ve been more specific (although I’d imagine not having sex for 10 years while having normal pap smears would qualify). The guidelines are actually much broader than low-risk:
    The USPSTF found no direct evidence that annual screening achieves better outcomes than screening every 3 years. Modeling studies suggest little added benefit of more frequent screening for most women. The majority of cervical cancers in the United States occur in women who have never been screened or who have not been screened within the past 5 years; additional cases occur in women who do not receive appropriate followup after an abnormal Pap smear. Because sensitivity of a single Pap test for high-grade lesions may only be 60-80 percent; however, most organizations in the United States recommend that annual Pap smears be performed until a specified number (usually two or three) are cytologically normal before lengthening the screening interval.

    The ACS guidelines suggest waiting until age 30 before lengthening the screening interval; the American College of Obstetricians and Gynecologists (ACOG) identifies additional risk factors that might justify annual screening, including a history of cervical neoplasia, infection with HPV or other sexually transmitted diseases (STDs), or high-risk sexual behavior, but data are limited to determine the benefits of these strategies.

    The whole article is actually quite interesting because it also describes evidence on other things I mentioned.

  • Anonymous

    One source of overtesting that’s overlooked here: information bias, the human tendency to want to collect more information even when we already know all we need to make an informed decision. It’s the tendency of a teacher to give another test over the same material, of businesspeople to postpone travel arrangements until they receive confirmation of ALL meetings at a particular venue, and of doctors to order more diagnostic tests when the data needed for diagnosis is sufficient.

  • Anonymous

    My daughter went to a gynocologist for a routine pap smear, then got a bill for $l500. for extra tests she never would have requested (mostly for veneral diseases). She’s in a monogamous relationship with her husband of several years. They claim she signed a form o.k.ing the added tests. But it was only a form agreeing to pay her bill in a timely manner. Her insurance will not cover these unnecessary tests. Is there any recourse? Also the statements submitted to the insurance say she has seen the doctor, when it has always been a nurse practioner. 2:45 pm

  • Anonymous

    Doctor, thank you for your honesty. I just left my doctor’s office this morning ending the professional relationship because of his insisting upon unnecessary testing for everything you can think of. He decided he could no longer treat me because I refused these unnecessary tests. I went in with high blood pressure which did not take long to correct with medication. I had no symptoms of anything else and my blood test came back with his stating how surprised he was at how good everything looked on it. Then he starting looking for things he could try to find wrong which had no basis in fact and from there the thing mushroomed into his taking offense because I would not follow his instructions for testing. Well so be it. I hope I can find a doctor as honest as you to take his place but I really doubt it.

    My husband was terrified by what he thought I should be tested for and thought I might be really ill. I am showing him your article to ease his mind.

    You are one in a million. Thank you.

  • Anonymous

    Also, in addition to my post of 4-14, 2008 about my doctor demanding unnecessary tests and refusing to continue to treat me for my high blood pressure if I did not submit to them, he wanted to check for heart enlargement and I asked him what he would do if he found that it was enlarged, would he give me another kind of pill? His answer was, “I am already giving you the same medication for your blood pressure that I would give you for an enlarged heart.” So I ask you, why then the test for the enlarged heart if I was already taking meds he would give me for it? Unnecessary test? You bet.
    Do the math.

  • Anonymous

    To: Anon @ 2:48

    I am also in the process of fighting with my soon to be ex doctor’s office about the same problem. I have never had an abnormal Pap Smear in 10 years, been with my husband for over 7 years, I waited 2 years in between tests because I have not had any abnormal Pap smears and my doctor before this one said I could and it would not hurt anything, and both me and my husband were tested for STD’s when we first got together.

    This is a new doctor because we moved to a new state. She was actually recommended to me as someone the nurses in the city go to. So I went in for a Pap Smear, a pregnancy test, and a prescription for birth control. That’s it. She never asked me to do the STD screening and never even brought STD’s up. If she would have I would have told her it was unnecessary because both me and my husband had previously been tested and we knew the results. I didn’t find out until my insurance agency refused to pay for the tests. Thankfully mine is only $105, but still. It is money that is needed for groceries that should not go for unauthorized tests. I go see her tomorrow (I had to make an appointment because she refuses to return my calls or even talk to me on the phone) to see how she can fix this or else I will be taking her to small claims court. I am not sure what else I can do. I had already decided to switch doctors when I saw she did this a few months ago. I am sorry, but I refuse to pay for tests that I never requested…that’s fraud. I feel kind of violated that they ran these tests without my knowledge and it makes me wonder what else they are going to do. It also makes me wonder if she is getting kickbacks for tests. I thought she was a great doctor during my visit and this is really disappointing to know she did this. How she handles tomorrow will decide what path me and my husband will take.

  • Michaela

    Diora – I think that's right…patients do need to be informed and demand to be treated as an individual. I don't have smears at all (gasp, horror)…
    Try mentioning that to any Dr and the hysterics start…
    The simple fact is…I refused to be treated like a sheep…
    The current screening system does not differentiate between high and low or no risk women.
    My husband & I were virgins when we met and have an exclusive relationship – I have never been exposed to HPV, so don't need smears. (confirmed by senior female gynaecologist to get the GP's off my back!)
    The tiny risk does not warrant 2 yearly invasive tests in my opinion and I'm the person paying for the testing – it's my body.
    If I wanted to cover every tiny risk, I'd be having my brain scanned and bowel examined as well…
    Thankfully, for the rest of you – there is a blood test on the way (the CSA test) that will replace smears – almost 100% accurate as opposed to about 70% for the smear test – a simple blood test. I can hear the shouts of joy from here…
    Search Medicine & Man and Cervius Pty Ltd for information about this Test.
    My advice – read up and find a Dr who will listen..not lecture, frighten or intimidate – we're women, not children.

  • Michaela

    I have some additional information that expresses concern about the dangers of over-screening women…there is increasing evidence that smears should not start before 25 or 30 because of the tendency to treat minor changes that would have cleared up anyway (more likely to happen with very young women apparently)…leading to invasive and unpleasant procedures.
    Women should think carefully before agreeing to smears without an interval of 3 to 5 years (if they need them at all) – more frequent tests appears to provide little benefit to the woman, but increases the likelihood of unnecessary follow-up…
    The smear is an inaccurate test – only 60-70% reliable, also Doctors are ignoring new guidelines for less frequent screening for their own reasons.
    The fear of being sued is probably a factor – pathologists are now sending back smears that would previously have been called normal as inconclusive, to be on the safe side, after a few law suits has made them nervous – thus women are suffering as a result with increased anxiety and more unpleasant re-testing and unnecessary procedures like colposcopy.
    I was shocked to see the US required virgins to have pap smears from age 18 – I’d challenge anyone to show the clinical value of that sort of testing.
    It’s so sad that this seems to happen to women – I’m not sure whether it’s a result of the days when medicine was dominated by males and a “paternalistic” approach prevailed and women were not trusted to make their own decisions…
    I think women really need to look at the clinical benefit of this testing and forget about the standard patter trotted out by most Doctors.
    A comparative chart of screening shows that in the US many women are being tested every 12 months which is unsupported in the rest of the world and by many health organizations within the States.
    http://www.nytimes.com/specials/women/nyt97/22gilb.html
    findarticles.com/p/articles/mi_m0815/is_/ai_n18744631

  • Michaela

    The chart I was talking about…
    http://www.mja.com.au/public/issues/176_11_030602/dic10690_fm.html

    Women might also like to research the clinical value of breast exams and pelvic exams in asymptomatic women.
    I was surprised to hear most US women are "required" to have a pelvic exam every 12 months – that doesn't happen in Australia.

    Self examination of your own breasts IMO seems to be the best protection from breast cancer.
    I attended a breast clinic when I was 20 & and was shown how to self examine – that way you become familiar with your own breasts.
    I'm currently researching the need for mammograms – they are being offered to women 50 and over…
    I'm afraid I don't trust the medical profession to make these calls for me – so I'll do my own research.
    I don't want to find they are of little clinical value or are in fact, harmful in 10 years time.
    If anyone is interested in some info on the clinical value & need for pelvic and breast exams in asymptomatic women, let me know…
    IMO the answer to taking control of our bodies is to be informed…

  • A.F. MELLO

    RECENTLY WENT TO MY DOCTOR COMPLAINING OF SERIOUS ON TOP OF BOTH SHOULDERS. HE THOUGHT IS WAS ROTATOR CUFF. SENT MY FOR AN X-RAY, THEN AN MRI, THEN EMG. AFTER ALL THIS RUNNING AROUND AND “EXPENSE” I’M BACK AT GROUND ZERO. WHY DID I HAVE TO GO THROUGH ALL THIS SERIOUS EXPENSE, ONLY TO COME OUT WITH ZERO RESULTS. WAITING TO SEE WHAT OTHER SPECIALIST HE’S GOING TO RECOMMEND. THIS IS A LITTLE ABSURD. WHY ALL THE TESTS?

  • Anonymous

    Because your problem is not a common one (which would have been found on those tests. The other thing is that you are not giving an accurate description of it. Your doctor continues to order tests because you continue to complain about it and they just want to find the cause of it and to treat it.