Why physicians order so many tests

Doctors “don’t want to miss anything”, and the fear of litigation is one reason for the exploding health care costs:

The third, often lamented, reason we “don’t want to miss anything” is because of an intense fear of litigation. The medical student is frequently reminded by mentors of the likelihood for lawsuits brought about by a missed diagnosis. As a consequence, the practicing physician has a tendency to practice defensive medicine, ordering as many tests and requesting a multitude of additional consultations in an attempt to stave off potential legal action. It is an unfortunate truth that the phrase “first do no harm” has taken new meaning when finished by “…to your attorney’s case.”

(via Mark Perry)

Comments

A patient
As a patient, I don’t want them to miss anything either. After all, it’s their job.
Criminallopath
The diminution of the value of a physician to that of a midlevel. Hence the use of the term provider. One need not pay a GP 130K per year just to order tests when one can pay a midlevel half that amount or less for doing the same thing – order a battery of tests and let the specialists figure it out.
Anonymous
Well then if you dont want to miss anything, lets just biopsy every organ in your body. You never know, there might be cancer hiding in there!
Anonymous
“A patient”, so you want any invasive test to test for 1/10000 chance that you have something, never mind that the risk of the test itself might be higher?
I am curious, if you were paying out of your own pocket, would you still want them to order expensive tests to test for 1/1000 chance of your having something? What if finding this something early wouldn’t make a difference, would you still want to know early?
The Happy Hospitalist
I found this article timely, as two of my near future blog entries will be about ordering tests and “the shotgun approach”
It was nice to see this docs view on things.
To anon 0208. Not missing something is never known until after the fact.
My job has never been not to miss anything. My job has been to be a doctor and not missing anything has never been a part of my job. I practice sound medicine. My job is to reduce the probability that you develop illness or reduce the probability that you progress in your already established chronic illness.
Your job as a patient is to practice healthy lifestyles which includes 2 1/2 hours a week of exercise, an appropriate diet, don’t smoke…
We all know that America’s patient does not live in this fantasy land.
Doctors do not live in a fantasy land either.
Not missing anything is not an acceptable bar of achievement.
The lawyers have created this unachievable bar and brainwashed the public into believing that medicine is a sterile environment without the possibility of complicated outcomes as an expected outcome.
Even quantum mechanics carries with it the Heisenberg Uncertainty principle, where by the actual attempts to measure data on an atom will interfer with the results you are trying to obtain. It speaks of probabilities, not absolutes.
Nobody is perfect, including physicians. The sooner the general public accepts that and starts managing their expectations, the better all of health care will be.
Anonymous
I just got out of the hospital where I spent 8 days due to pneumonia. The residents who treated me were concerned about my vomitting (I was on Zofran for 6 days) and sent me for a sonogram of my gallbladder, liver and pancreas. There were “spots” on my liver that should be “watched.”
Then on discharge day one of the residents came to tell me they had scheduled a CT scan of my liver. I asked why and was told to determine what the spots were. I asked what thepossibilities were and was told cysts, some type of growths on the outside that would just be watched, and cancer. “But we don’t think you have cancer.” Since possibilities 1 and 2 just meant watching there was really no reason for the CT scan other than to protect them from liability if, against all odds, I did have liver cancer. I told the resident I didn’t have medical insurance and couldn’t afford the CT and she cancelled it. I don’t know how I’m going to pay for my hospital stay. I have been rejected by numerous insurors because five years ago I spent two weeks in the hospital with severe depression.
The Happy Hospitalist
Anon1251, for starters don’t pay anything. When you get your bill from the hospital go down to their billing department and tell them you can’t afford to pay the bill. Most hospitals will accept something in full rather than nothing in full.
Fill out paperwork for the indigent. Speak with their social workers. They may be willing to drop a huge portion of your bill in exchange for payment of a small percentage.
Give it a shot. Many hospitals will right off a portion of their care for “their community service”
Also, they will write off the full value of their service, even though insurance companies will only pay pennies on the dollar of what they actually charge.
It allows them to inflate their “community service”
offer to pay a small % in full in exchange for nothing. You might be surprised. They may take it.
The cost of your “indigent” care is built into their fee structure for everyone else in the world with insurance.
Andrew Schamess
This is a good post and I agree with the comments so far.
One less-considered effect of habitually ordering multiple tests is that you produce a lot of data which require time and effort to interpret. This can have a negtive impact on your overall clinical practice.
As we know, tests often find clinically irrelevant data (a slightly high calcium… a subcentimeter nodule on chest CT…) that nonetheless require additional testing, follow up, etc.
The danger is that in all this data, the patient’s real problem gets lost. You spend all your time and energy pursuing red herrings, rather than using good clinical judgement to get to the heart of the matter.
Furthermore, there are only so many hours in your day. The time spent “ruling out” cancer in a twenty-nine year old with headaches
and weight loss that are much more likely due to depression, is time NOT spent taking a careful history from a 75 year old with new onset constipation, who may actually HAVE cancer.
Shotgunning tests doesn’t produce good results clinically or legally. There is no substitute for paying close attention to the patient’s problem, and applying your knowledge and experience to solving his or her problem.
Good clinicians order tests to confirm what they suspect based on history and physical – not to “rule out” diagnoses they think clinically unlikely.
Anonymous
“The medical student is frequently reminded by mentors of the likelihood for lawsuits brought about by a missed diagnosis. “
Then the student has uneducated mentors. They should be teaching the student how to treat his/her patient, because that has a much, much greater effect.
Anonymous
“The lawyers have created this unachievable bar and brainwashed the public into believing that medicine is a sterile environment without the possibility of complicated outcomes as an expected outcome. “
Given that the vast majority of errors never result in a lawsuit, this statement is obviously wrong. However, if anyone has set the bar high, it would be medical industry marketing.
Anonymous
The danger is that in all this data, the patient’s real problem gets lost. You spend all your time and energy pursuing red herrings, rather than using good clinical judgement to get to the heart of the matter.
The other danger is the risk of additional, more invasive, tests ordered to pursue this “something”. Another danger is finding something that would’ve never threatened one’s life if remained undetected yet when detected will need to be treated and the treatment may have serious even life-threatening complications.
Tests aren’t risk-free. In our society a lot of media attention has been given to promotion of tests, but hardly any was given to tests risks.

Why physicians order so many tests

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