Before ordering a test, know what to do with the result

Insanity: Doing the same thing over and over and expecting different results.
- Albert Einstein

As medical students rotating through the wards, we spent a significant portion of each day ordering laboratory tests and then chasing down the results. We wanted to investigate our patients’ illnesses and, just as importantly, we wanted to be prepared for any question with which our professors might surprise us during Attending Rounds.

One day, as I was hurriedly checking boxes on a laboratory order form, my resident challenged me to justify one of the blood tests I was requesting. “You can order that test after you answer these two simple questions …” His eyes narrowed. “First of all, what exactly are you going to do with the results? And, second, who is going to pay for it?”

He became increasingly impatient while quizzing me about all of the potential outcomes. Clearly, I would need to spend my afternoon reading in the library. I also admitted that I had no idea how much the test would cost or whether the patient’s insurance would provide coverage. It turned out that this was, indeed, a very expensive blood test that was only performed in an out-of-state laboratory. The results would not be available for several days. Checking that box would have cost the patient several hundred dollars; by the time the result was available, it would have been all but meaningless. “Aha!” my resident chided me triumphantly, “Do you still want that test? You need to make an effort to understand the impact and cost of everything you order.” I had learned a lesson and sheepishly tore up the slip.

My memorable medical school incident came back to me last week while reading an editorial in the New England Journal of Medicine. Dr. Howard Brody reminds us that high-cost care is not necessarily better care and that a study of regional variation recently showed that “nearly one third of health care costs could be saved without depriving any patient of beneficial care.” Cost-effective care is possible.

Since physicians order tests, Brody suggests physicians need to be at the forefront to curb healthcare expenses. As a start, he proposes that each medical specialty create a “Top Five” list of its most commonly ordered, expensive tests and treatments for which there is little evidence of any meaningful benefit. The specialty would then be charged with educating its own members.  In “In short, the Top Five list would be a prescription for how, within that specialty, the most money could be saved most quickly without depriving any patient of meaningful medical benefit.” In the best of worlds, this approach represents utilization oversight driven by providers rather than insurers or government.

Resource consumption — be it money, time, supplies, or energy — is a real-life dilemma in every medical center; in medical care, there are just so many places where simple decisions carry a fiscal wallop. Three quick examples: Technology is routinely touted as providing improved safety and efficiency, but, sometimes, it adds cost without any proven benefit whatsoever. Adding one more test or ordering one more consultation at the end of a clinic visit “just to be certain” quickly adds up when repeated hundreds of times each month. And, of course, any provider who can spell “PET Scan” can order one.

We can all play a role in cutting costs. I tend to avoid technology unless I can show that it is truly going to benefit a particular patient. For example, I recently saw a patient for a second opinion. His community physician had recommended an extremely expensive test. After reviewing his records, I told him that there was no reason to have the test performed. He was understandably skeptical. “Why did the other doctor think I needed it?” He frowned. “She said it would be very useful. Shouldn’t you order it anyway?” We had a long conversation. Deciding not to “do something” can be a hard sell.

Even now as we engage in a national discussion about health care, it seems that the questions still come down to these two: What exactly are you going to do with the results? Who is going to pay for it? On both an individual level and as a society where we all depend on each other, these two questions are just as relevant — and difficult — today as they were when my resident made me stop and think about a box that I had checked on a laboratory slip so many years ago.

Bruce Campbell is an otolaryngologist who blogs at Reflections in a Head Mirror.

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  • http://www.neurokc.com Vernon Rowe

    Amen, Dr. Campbell

    The fact is that there is no such thing as a bad test. People just make them that way.

    If a test is inappropriately ordered, poorly performed, poorly interpreted, and poorly utilized by the treating physician, that particular test in that particular patient is a waste of time and money in an already overtaxed health care system.

    On the other hand, if modern testing is appropriately ordered, expertly performed, and interpreted by someone who knows how to use it for diagnosis and treatment in a particular patient, then modern medicine is an amazing thing to behold.

    As a neurologist, I would not want to go back to the pre-MRI days for every patient. I have to go there often enough for patients with pacemakers and hardware, and it isn’t pretty.

    Bottom line is Dr. Campbell is exactly right. Don’t order a test unless you yourself know how it will be performed, know what the results will mean, and know how you’re going to use those results to care for a particular patient.

  • http://www.tjgmd99.wordpress.com Thomas Gerke, M.D.

    well said and stated…i have ALWAYS said “don’t order a test unless you are prepared to deal with the results” and you should anticipate the result based on your H & P …the horror of SHOTGUN LABS!!!

  • http://www.depressiondocs.com Dheeraj Raina

    Thank you, Dr. Campbell. Your article reminded me of an experience in medical school.

    When I was a 3rd year medical student, during internal medicine rounds one day the intern listed the tests he would order and the attending asked him to explain what he expects to learn from each test he had mouthed off and to also explain how that the results could potentially change his management of the patient. The poor intern’s explanation began with, “Some of the tests are routine tests, like CBC…” The attending interrupted and said, “What do mean by routine? Do mean you order some tests just as you brush your teeth or take a shower or every day?” I don’t even remember the name of the intern or the attending anymore, but remember the scene and the faces of the people involved and that statement and everything it stands for – Don’t order a test unless you know what to with it.

  • http://diagnosticinformationsystem.com Bob Coli, MD

    Dr. Campbell,

    Einstein’s definition of insanity also directly applies to all existing EHR, PHR and HIE platforms that continue to use archaic, infinitely variable formats to report cumulative test results to physicians and patients as fragmented and incomplete data.

    Because the HIT vendors have ignored this flawed user interface design since the mainframe computing era, a group of private office-based Rhode Island physicians is independently developing an intuitive, standard format that can display results as integrated information on up to 80 percent fewer screens and printed pages. Once operational, it will also incorporate user-friendly clinical decision support for efficient selection and interpretation of the 6,500 different diagnostic tests now available.

    The Diagnostic Information System (DIS) content exchange standard reporting format is described and illustrated at: http://diagnosticinformationsystem.com and in two SlideShare presentations on my public profile at LinkedIN.

    Despite the significant potential value of the DIS standard format for enhancing physician and nurse workflow, minimizing redundant testing costs and improving quality and patient safety, we have not yet completely overcome all of the barriers to truly disruptive technology innovation that are embedded in the American healthcare industry. However, we remain optimistic that we will ultimately succeed because of the limited usability of contemporary ambulatory and inpatient EHR, PHR and HIE platforms and the fragmented and immature nature of the competitive markets for these vital technology products.

  • Phil Bain

    Good post. I remember as a 4th year “shadow” (medical student) at Charing Cross Hospital in London over 20 years ago that we were charged with drawing all of the necessary bloodwork for our patients scattered throughout the 15 story hospital with 2 elevators ( 1 of which always seemed to be broken). We had to draw the blood using tubes with small plastic beads in them ( pre vacutainer) and hand deliver them to each specific dept- hematology was on the first floor, chemistry was on the 6th floor, micro was on the 8th floor- you get the picture. This taught me very early on that I could either order a lot of tests, some of which may have had marginal value or only order and deliver the tests that were absolutely necessary for the care of the patient. A great lesson indeed.