How can doctors minimize unnecessary testing?

A recent comment raised a minor controversy about the strategy of minimizing tests.  I actually do not think that the disagreement is that great, but I feel like exploring the issue.

This is the sentence that triggered the comment, courtesy of primary care physician Rob Lamberts:

Order as few tests as possible.  No test should be ordered for informational purposes only; the question, “What will I do with these results?” should always be answerable.  If it is not, the test should not be done.


Like the Supreme Court we have two options.  We can try to ascertain original intent.  I guess I could write Dr. Rob and ask him, but that would not be as fun.  Or we could develop our own interpretation of this paragraph.  I favor B.

The key here is “What will I do with these results?”

What are the possibilities from tests?

  1. We use tests to make diagnoses
  2. We use tests to exclude diagnoses
  3. We use tests to follow and adjust treatment
  4. We use tests to estimate prognosis
  5. Sometimes we order tests so that in the future we will have a baseline

The real question here is the phrase “informational purposes only.” Information is often valuable, it depends on the clinical situation and the patient.

I would amend this paragraph to include an avoidance of unnecessary tests.  What is an unnecessary test?  I would suggest that we should consider a test unnecessary when we already have the information, the same test recently, or the probability that the test would provide useful information is very low.

Perhaps one or two examples will help.  A patient sprains his ankle playing basketball.  You apply the Ottawa Ankle Rules and determine that the patient does not need an X-ray.   But you order an X-ray anyway.  That is an unnecessary test.

An 18-year-old woman comes to student health complaining of a sore throat.  She is coughing, has had no fever, has no exudates and no anterior nodes.  Doing a rapid strep test is unnecessary, the history and physical have excluded the diagnosis.

A patient comes repeatedly to the ER with chest pain.  The patient gives the same history each time.  We have 3 previous chest CTs that exclude pulmonary embolism, yet another one is done.  Not only is the test unnecessary, but it could actually harm the patient in the future.

One cannot easily develop rules for testing because the presentations that we see vary so greatly.  Test ordering becomes an art and the application of evidence.  I sometimes order tests for information, if that is the only way to gather the information.

We should clearly minimize testing, especially expensive testing and thus part of the art of good medicine is the appropriate use of testing.  So I will declare that Dr. Rob’s original intent fits that concept.

Robert Centor is an internal medicine physician who blogs at DB’s Medical Rants.

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  • stitch

    Earlier this week I got an irate phone call from a mom about the physical I had done on her aged 18 to 24 year old kid. Physical was for work, no blood tests were required, patient was healthy, no flags on history. I offered blood tests but explained they were not required and the patient declined.

    Mom was irate, I mean irate, that I had not done “everything” to find out what was going on with her kid. Without betraying confidence I explained that, according to history, exam, and guidelines, testing was not indicated. Mother refused to be placated. Will likely speak to another doc in the practice and make sure the kid gets the blood work; or will file a charge against me and slam my all-important ratings.

    Another: today in the office one of the front folks started talking about a friend of a friend who was diagnosed with cancer; during the discussion this person said everyone with cancer should get a PET scan because you want to know what’s going on. No, this person is not on the clinical side, but clearly we need to have a discussion…

    I spent two visits yesterday explaining results and further testing with a couple both of whom had had local “screeening” tests, which were, of course, free.

    I saw another patient today who had an abnormality on a chest CT that needs to be followed up; the chest CT was done as part of a total man scan following a fall and a complaint of lower abdominal pain. What was overlooked in this evaluation was the clearly fractured wrist! The abnormalities on CT are miniscule but because they have been identified (classical “incidentalomas,” we need an ICD-9 for that) they need to be followed up.

    I cannot tell you how many times I have had the discussion, both virtually and in real life, about the problems of scattershot or “complete” testing of everything. I’ve spent countless hours of my life explaining, or trying to explain, whether a test was something to be concerned about, or why further testing is needed because I don’t think something is significant but it cannot be ruled out. In addition to the anxiety it generates, it also creates tremendous costs for the system for very, very little benefit to patients.

    What we really need to be doing here is thinking. Plain and simple. But we’re not training people to do that anymore. And we’re sure not paying people to do that.

    • Dr Pi

      couldn’t agree more. We are not being paid to teach patients how to avoid tests but to order them and we are considered “not thorough” if we don;t order and test and test. How many times have I have to tell patients, “No, I will not order a Blood Type on you so you can go on the ‘blood type diet’”. Beyond silly and time wasting.

  • http://nostrums.blogspot.com Doc D

    Two decades ago I had a similar patient with a sprained ankle. The history was straightforward. Findings on exam were minimal. I told him it was a sprain.

    He said, I heard it pop (we’ve all heard that one before). He thought an X-Ray necessary. “How can you tell, otherwise?”.

    Did I mention he was a lawyer? He was.

    I felt pretty sure. Then he said he was deploying to SW Asia in 48 hours. I thought, what the heck? and did the film.
    It was normal.

  • http://fertilityfile.com IVF-MD

    I agree.

    Now imagine how this all changes when the irate mom and the deploying lawyer have to pay for the tests and the x-rays themselves.

    The mom all of a sudden asks, “Do we really need all these tests? After all, the exam is fine.”

    You ask the lawyer, “Would you like me to order the xray for you or shall we save you the money and just observe it for now? I suggest not getting it, but without it, I can’t 100% rule out a fracture. Up to you. If you decline the xray, please sign here.”

    A lot of money will be saved on healthcare when there is accountability by the patient.

  • http://www.medicalisland.net Dr. Lawrence Kindo

    I completely agree with the author on this one – unnecessary test is not equivalent to a test done for informational purpose. Being from a third-world country, I often think in my practice what test could be avoided. We often have to compromise even on costly antibiotics with alternatives that might not meet the needs of the patient. It all boils down to “Can the patient afford it?”. There is a dearth of medical facilities that consider ethical issues a part and parcel of providing health care to the poor.

    There are cases here which would have required an investigation but was avoided for financial reasons, while on the other hand there are situations where a “blanket battery” of tests is done just to rule out any possibilities. Of course, corporate hospitals dread being pulled up in court, but that need not incite “blanket battery” tests ordered left and right.

    Let’s be reasonable – India needs more resources if we were to deal with a simple ailment like a common flu with a battery of tests just to rule out any possibilities.

  • http://www.occampm.com/blog Michelle W

    I can well believe there are irate moms beating down doctors’ doors about things. While many of them are no doubt demanding unnecessary testing, I would point out that sometimes the mom demands it because she, actually, knows just a little more about her child’s medical situation than the attending pediatrician. Not in terms of the complete medical chart, but in terms of what that child has been exposed to recently, what the child has suffered from in the past and what worked then.

    A mother of three I knew became intimately familiar with how her children reacted to an illness. Often she would have “diagnosed” them based on prior experience before picking up the phone to schedule an appointment. Some of the pediatricians would respect her knowledge and insight, some wouldn’t. Of course, she soon learned to ask for the more understanding doctors when available. I am not using this example to say that a mother’s demands always be met: certainly, the attending doctor should use superior medical knowledge to diagnose and decide when a test is necessary.

    However, the concerns and/or requests of a patient or the patient’s guardian shouldn’t automatically be dismissed. At times, they really do know what they’re talking about.

    • JustADoc

      Obviously I don’t know the kids in question, but I have known patients who had seen these ‘better’ doctors who treated their recurrent sinusitis ‘correctly’ based on the patients knowledge of their own history. A review of records oftern revealed that when given antibiotics they got better in 7 days and when not given antibiotics they got better in a week.

  • Rusty

    I agree 100% with the author and with all the replies so far. Working in a teaching hospital I get a glimpse of what med students, interns and residents are taught and compare it to my own experiences many years ago. Dr. Pi’s comments stating that we are not being paid to teach patients how to avoid tests but to order them reminded me how for numerous reasons clinical medical education now teaches new doctors not to use the knowledge and skills that they’ve learned but to rely heavily on testing and imaging as a crutch or substitute for good clinical skills. Sometimes it appears as if we’ve become afraid to use our brains out of fear of being wrong and being sued and we’re passing this fear on to the next generations.

  • Hexanchus

    Michelle,

    I agree with much of what you said, but your comments are not contextual or relevant to stitch’s post. The “kid” in question, was not a child, but an 18-24 year old adult. The exam was not for a medical issue, but simply a pre-employment exam – patient was healthy with no history flags.

    The “mom” in this case was way off base and needs to butt out. Legally she has no input with respect to any medical care for her adult “kid”. Even had there been reason to recommend further testing, the adult “kid” patient had the right to decline, and it’s still none of the mom’s business. It’s about time she learned to cut the apron strings…..

    I can appreciate stitch’s efforts to be diplomatic without violating the patient’s confidentiality, but the bottom line is that since the “kid” is legally an adult, it is against the law for him/her to share any information regarding the patient’s medical condition with any 3rd party without the patient’s explicit permission. As often happens, trying to be nice can turn around and bite you. Perhaps a better approach would be along the lines of ” I appreciate your concerns, but because your child is legally an adult, both state and federal law prohibit me from discussing any aspect of their medical care with you without their explicit written permission. Is there anything else I can help you with today?”

  • http://distractible.org Rob

    DB is right. My example is the MRI scan on the person with new-onset sciatica. For me, the main reason to order an MRI is to decide if the person needs an intervention. The indications for surgical intervention are: 1. Intractable pain, 2. Progressive neurological deficit. Neither of these can be determined for most new-onset radiculopathy before treatment is tried. I give the person prednisone +/- physical therapy (depending on severity and length of symptoms), and most get better. Some probably do have herniated discs, but I don’t care as long as they get better. I don’t need to know if they have a herniated disc, I need to know if I need to refer them to a surgeon or pain specialist.

    That is what I meant by “informational purposes only.” By the way, I also think lipids in kids are a bad idea based on this principle, as we don’t put kids on Lipitor except in extreme circumstances….but that is another post.

  • drhawk

    I would like to disagree. A test is something that is done to prevent an adverse result or to enhance information. From this point of view, we would do routine testing on a patients kidneys to make sure the contrast load we are about to inject would not cause failure. It would also cover shooting that mans ankle to make absolutely sure we do not miss the 1 in 1000 fractures that are missed by the ottawa ankle rules. As well, the fourth CT scan on the man wih chest pain would ALWAYS be done in any er I was working in. Why? because a lot can change in 24 hours. just because he did not have a PE yesterday, does not mean he cant have one today.

    Although I can understand the need to reduce testing, this is something that should be looked at more in primary care. In an environment like the ER, you really have to catch 100 percent of the things 100 percent of the time. there is no luxury of repeat testing, or follow up. the two best things I heard in residency 1) it is better to spend the patients money than to have them spend yours 2) always treat and test every patient as if you were the last person they were going to see, because most dont follow up and dont follow instructions.

    Remember that a lot of the ‘clinical rules’ for testing were developed in countries where health care is socialist, rationed, and limited, and is applied by people who do not have the Damocles Sword of lawsuits hanging over their head.

    I think to really address this issue you have to stress two or three points:

    1) malpractice needs reform
    2) patients expectations need to be lowered, sometimes things will get missed
    3) pain is not a disease requiring extensive testing at all times

    I dont see this issue being resolved either way. Under Obamacare, once the rationing starts, and it will start, clinicians are not protected from judgement based on tests they are not allowed to order. over-testing will continue as long as the public expects it and clinicians are penalized for missing the unexpected.

    • steve weaver

      I agree 100%. And doctors have to be right 100% of the time. To be wrong is to risk being sued. You don’t know that until you’ve been there. And I’m not willing to risk my future for the costs of healthcare.

  • http://www.skincancercenter.com Dermatologist Los Angeles

    Awesome look into these comments. I agree it would be easy to ask Dr. Rob what he was thinking, but your way was far more fun. Oh and did I mention, Spot on!

  • Anon EM doc

    How humble of you not to toot your own horn in your “rule-out strep throat” example, Dr. Centor ;)

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