Are doctors ordering too many tests, or practicing a new standard?

Are medical students and new doctors overly reliant on tests and technology to make diagnoses?

Are doctors ordering too many tests, or practicing a new standard?That’s an interesting thought I had when reading the latest TIME.com piece from emergency physicians Jesse M. Pines and Dr. Zachary F. Meisel.

In their article, they give reasons why doctors order too many tests.

Of course, they cite defensive purposes, saying, “once a doctor has presented an M&M [morbidity and mortality], she will probably never make that same mistake again — but she may start ordering more tests on her patients for minor symptoms.”

More interesting is how they say young doctors have grown up and learned with medical technology readily available, and have grown to depend on them:

Radiology tests have become a crutch: doctors in training are no longer taught how to distinguish patients who need testing from those who don’t. A decade ago, a surgeon would spend time interviewing and carefully examining a patient to help decide if he or she needed a CT. Now, many surgeons, especially the younger ones, won’t see a patient until the CT is complete. Testing has become more of a reflex than a higher-level decision … Could it be that younger doctors are simply less likely to view imaging tests as defensive, considering them instead as the standard way to make a diagnosis?

In a recent New York Times op-ed, Stanford physician Abraham Verghese echoes this sentiment. He has written extensively about the iPatient, and how computers and technology has made the doctor-patient relationship more opaque.

In his piece, Dr. Verghese notes that,

[physical exam] training can be undone the moment the students hit their clinical years. Then, they discover that the currency on the ward seems to be “throughput” — getting tests ordered and getting results, having procedures like colonoscopies done expeditiously, calling in specialists, arranging discharge. And the engine for all of that, indeed the place where the dialogue between doctors and nurses takes place, is the computer.

It seems that medical students today are spoiled by the easy access to the latest in imaging equipment and medical technology, and have become less dependent on physical exam skills previously relied upon in the past.

That, perhaps, is the bigger driver to the increased reliance on tests, rather than the threat of a malpractice lawsuit.

Drs. Pine and Meisel may be on to something. Instead than seeing today’s test-ordering as “overtesting,” doctors may simply be practicing according to a standard of care they’ve become accustomed to.

 is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on FacebookTwitterGoogle+, and LinkedIn.

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  • http://www.davisliumd.blogspot.com Davis Liu, MD

    Certainly reimbursement plays a role in fostering or diminishing a particular behavior, but I completely agree. That is why I think Dr. Verghese is the Top Gun in American medicine. The new generation of doctors are too reliant on technology as the acceptable standard. http://davisliumd.blogspot.com/2010/10/abraham-verghese-top-gun-of-american.html

    Patients, unfortunately, falsely believe this as well. The media and doctor TV shows, like House, ER, equate good care with imaging and lab testing when in fact it still is the time honored ritual of taking a history and doing a physical exam.

  • Smart Doc

    The standard of care has been set by the courts.

    • Greg

      Agreed, SmartDoc…what lawyers often forget to understand is how doctors informally consider precedent set by malpractice cases in determining a local standard; it’s the “did you hear what happened to George in Ortho?” gossip in the doctors’ lounge or while scrubbing into the OR. Med school professors or academic societies may set all the evidenced based standards, but in a doctor’s mind they don’t hold a candle to an anecdote about how a colleague got taken to the cleaners on a malpractice case. An oft-cited example is the head CT scan in the ER for headaches – careful scientific research says it’s useless, but every ER doc has a “guy who knows a guy” sort of story where a doctor was sued for malpractice for not ordering the CT. So what happens? The doctor listens to science and reason and refrains from ordering the CT. Nope, and the costs go up and up!

      • Matt

        If physicians are using cases they’ve never seen a record in, that they’ve heard about third hand or read a blurb in the paper about, in making medical decisions, that calls into question their diagnostic abilities in the first place.

        However, the defensive medicine argument is largely academic, since the only solution proposed – damage caps – has never actually reduced defensive medicine after multiple decades of using them.

        • Smart Doc

          “However, the defensive medicine argument is largely academic, since the only solution proposed – damage caps – has never actually reduced defensive medicine after multiple decades of using them.”

          I am not sure if this is true, especially given the lawyer industry source of this assertion.

          However, damage caps certainly keep liability insurance rates a lot more affordable.

          • Matt

            Actually, I was just looking at the overall cost of healthcare in capped and non-capped states. That’s not a lawyer-non/lawyer stat is it?

            What’s not true is your last claim. Rates go up and down with the economy, in both capped and non-capped states. But really, why do you care? Are you interested in reducing malpractice and compensating the victims of it, or just in saving a few bucks for insurance carriers and hoping they pass it down to you?

  • stitch

    I am an advocate for evidence based medicine, but I think we also need to realize the role that that may have played in the increased use of testing. To conform to the evidence, one needs something that is measurable and verifiable. Unfortunately, physical exam skills do not conform to measurable, reliable data.

    We have taught a generation of physicians to think in “pixels” of data, not in terms of soft information like physical exam skills. We don’t value thinking enough at any level. Any wonder why there are those who think Watson will replace us?

    • knasky

      Great point. It’s near impossible for physical exam findings to work their way into EBM-driven guidelines.

  • Jackie

    Medical technology is only as good as the doctor who uses it. My life-long brain tumor would have been found 5 years earlier had the doctor ordered a CT/MRI scan of the head 26 years ago. He ordered everything – chest X-rays, lab work, EKG (discovered ‘Mitral Valve Prolapse’), colonoscopy…etc. after correctly diagnosed ‘Erythema Nudosum’. But the Merck Manual at the time had stated that ‘some EN cases are caused by unknown reasons’…

    When my Breast cancer recurrence was finally confirmed (ended up calling the original surgeon to order an earlier ‘annual’ mammogram), I reviewed my blood test results of the previous 4 years and realized my doctors never had regarded some of the ‘odd’ numbers as warning signs.

    After and two different cancer diagnoses and recurrences and 5 major surgeries, I know now that whenever my weight falls down to the ‘baseline’, there’s something wrong…

    Long time ago, Hubby introduced me to a phrase: “Just because you are paranoid, it doesn’t mean there’s nobody out to get you.” :) I’d hope more doctors are adopting the attitude that ‘just because your patients are paronoid, doesn’t mean there’s nothing physically (or mentally :) wrong with them.’

    • knasky

      Yeah, it’s a pretty widely dispensed axiom in medicine: Even hypochondriacs get sick.

  • http://www.TheHealthCulture.com Jan Henderson

    Interesting ideas here. What seems to drive excessive testing is a combination of greater availability, what’s accepted as standard practice, defensive medicine, and — to a small but measurable extent – financial interest.

    One problem with the increase in testing is overdiagnosis. I just read H. Gilbert Welch’s new book on the subject (http://amzn.to/hRuOMT). He’s very sympathetic to the doctor’s predicament. An imaging test ordered in response to chest symptoms could reveal abnormalities in the abdomen. Chances are it’s something that will never cause symptoms and will not be the cause of death. If you tell the patient, the patient may spend the rest of her life worrying unnecessarily. Worse yet, she could seek and receive unnecessary and potentially harmful treatment. But if you don’t mention it, you’re taking too big of a legal risk.

    • Matt

      What is the legal risk? You say it’s too big – so how big is it? Is it bigger than say, speeding 10 mph over the speed limit? Or any of the myriad other interactions we encounter daily?

      And what exactly are you risking? And by doing X or Y test, how much have you reduced that risk?

  • http://www.edwinleap.com/blog Edwin Leap

    There are two other reasons for increased test ordering in the emergency department. One, we have no control over volume so we have a limited time to see and evaluate everyone. While a step-wise, sequential ordering scheme may be cost-effective, we often work in parallel to save time and ensure that dangerous etiologies aren’t missed. Many facilities have extreme pressure, due to patient satisfaction scores, to turn volume. ‘We’ll see you in 30 minutes or your care is free,’ etc. Two, many times emergency physicians call consultants to come and see/examine a patient and they drive the testing. If I say, the patient also has a headache, or mild abdominal pain, or anything that might be evaluated by imaging, the admitting physicians typically insist on the test. Including surgeons for appendicitis that is totally textbook. I’m not saying they shouldn’t ask for testing; they’re subject to the same litigation pressures as we are. But the emergency physicians often would order less tests, but are compelled to order more.

  • http://cureprematurehelp.com Premature John

    I would say that there is no way that more technology and a more scientifically precise diagnosis can be looked down upon. There is a reason why life expectancy has been increasing, and it is not because doctors are smarter now. The technology they use is smarter now.

    • Diora

      And what about extra cases of cancers that are caused by unnecessary cat scans? I am sorry, but I don’t want to have a CT unless I actually need a CT i.e. unless my chance of benefiting from this exam is an order of magnitude higher than my chance of getting cancer from it.

  • http://skepticalscalpel.blogspot.com/ Skeptical Scalpel

    Practicing EBM will not necessarily save you. I refer you to a 2004 JAMA article by Daniel Merenstein. It was in the “A Piece of My Mind” section. In it, he describes a lawsuit against him for not ordering a PSA on a patient who eventually died of prostate cancer. He was a resident at the time of the patient encounter. Although he had numerous experts defending his use of evidence-based medicine principles, his residency program was found negligent by a jury which awarded the plaintiff $1M. Here is the link http://is.gd/pisc2Y. Unfortunately, you can only read the entire article if you subscribe to JAMA or have access to OVID.

  • http://www.drdialogue.com Juliet K. Mavromatis, MD

    Move over stethoscope, reflex hammer, black bag, we’re living in the 21st century. These age old symbols of the profession along with our Oslerian physical exam rituals may be somewhat outmoded. I agree that medical technology cannot substitute for excellent history taking skills–listening to the patient, speaking with his or her other physicians, taking time to explain to a patient why one is not ordering a chest x-ray. But, is the physical exam really evidence-based? Perhaps we actually over-emphasize teaching the physical exam in training our students. Many elements of the physical exam are useful (the skin exam, the neurological exam) in helping make a diagnosis, but rather than auscultate the heart, how much better would it be, cost aside, if we could echo every patient with our smartphone and discard the archaic18th century stethoscope ? Technology is not the villain here, it’s the breakdown of trust within the patient-physician relationship–inadequate communication, fear of litigation, lack of time with patients (& reimbursement for talking to them) that causes doctors to order tests indiscriminately.

    • http://www.TheHealthCulture.com Jan Henderson

      Good points, Dr. Mavromatis. The history of the physical exam has been brief. Doctors were reluctant to use a stethoscope (invented 1816) until about 1850. Physicians (who looked down on surgeons) didn’t touch patients, except taking the pulse at the wrist. There was no physical exam due to a combination of the prevailing (non-scientific) theory of medicine and what was considered improper behavior (observing parts of the body that were normally unclothed). More at http://bit.ly/fxfj2a, http://bit.ly/fQSUMh, and http://bit.ly/gOmUno.

      This may be the exception that proves the rule, but I once read an article (http://bit.ly/hQ5h8X) that told the story of a 23-year-old man who was diagnosed and hospitalized with a life-threatening pulmonary embolism. He received extensive testing — CT scan, consultation with a hematologist, a coagulation work-up — but the results were all negative and doctors were unable to identify a cause. The recommended treatment was anticoagulation medication, which would mean this highly athletic young man would have to give up his passion for weight lifting, swimming and running.

      Then a doctor, noticing how muscular the man was, tried a simple test. The patient straightened his arm, and the doctor felt the pulse at the wrist. The patient then put his arm behind his back and turned his head. The pulse disappeared. When he looked forward, the pulse returned. He was diagnosed with thoracic outlet syndrome, underwent surgery, and returned to his active life.

  • Marc Gorayeb, MD

    The best way to reverse this degeneration of medical practice is for the patient to have a financial stake in the interaction. A young woman with abdominal pain asked me whether a CT scan was really necessary, because she had “crappy” insurance from her employer with a high deductible. I replied that in my opinion, she could safely wait a day or two before having the test; her symptoms were likely to subside, and the test would probably be unecessary. I was able to exercise my medical judgment, and the patient was able to participate rationally in the decision; it felt liberating.
    It’s “crappy” insurance for individuals who expect or demand gold-plated first-dollar insurance coverage, but it’s the kind of insurance that can restore sanity in our health care system.

    • A Sarah

      I have good insurance with low deductible and copay and often find myself asking this question, and I get looked at like I just sprouted another head! I am asked, “Why _wouldn’t_ you want the test?” (Less so when it’s something like a CT scan with known cumulative risks to me, more so when the risks to me — EEG, Pap smear — are minuscule to nonexistent. My answer is that I am not in the habit of buying things I don’t need.) There seems to be an attitude of, “If it doesn’t hurt, get it!”

      • A Sarah

        Oops, sorry, I misspoke about the EEG; the neurologist freely admitted he would be ordering it only out of professional curiosity and that I was free to decline, so I did. (I had met my deductible, so it wouldn’t have cost me anything.) Wish I could edit posts!

      • stitch

        On the other hand, there are patients who will ask me for tests all the time, because they are not at financial risk for it. For some people the attitude seems to be “what’s the harm in it?” Trying to explain that testing willy-nilly will statistically lead to abnormal results for normal things, that then need to be chased, doesn’t go far with some people.

        • http://www.TheHealthCulture.com Jan Henderson

          Starting in the 1970s and 80s, for various economic/political reasons, there was a campaign to convince the public that everyone was personally responsible for their health (thereby relieving governments of the responsibility to do things like regulate industries that pollute the environment). Many people – myself included – became much more health conscious. Add to that advancements in medical technology and it makes sense that we would now have rampant overdiagnosis.

          Welch sums it up as choosing to pursue health or disease. Some people would prefer to minimize their medical contact, even knowing that may mean a slightly higher risk of death or disability. They’d prefer to see a doctor only once they have symptoms, not when they’re feeling well.

          The irony is that people who seek medical care because they are preoccupied with their health, believing this will decrease their chances of death or disability, are more likely to be diagnosed with an abnormality that will never give rise to symptoms and will not be the cause of their death. As Welch writes, it’s “difficult to promote wellness when actively looking for things to be wrong.”

  • Kc

    I think that this is the new standard of “cover all possibilities”. After all, what is the incentive to practice low cost care. The patients don’t care about cost because of the third party payer system. Infact, the cost of a medical test or treatment never comes up in medical decision making. In addition to that, you have the risk of frivolous lawsuits.
    For medical care to be cost effective, you either need a free market system where patients shop around for the best cost effective care or it has to be a single payer system where the government decides what to pay and when to pay. The current system as we all know has not been working.

    • gzuckier

      It’s also important to note that “normal” people are not inclined to want more tests, scans, operations even if “free”, the same way they might be attracted to a free ice cream cone; medical care is, almost by definition, a pain. At very least, time-consuming and rather unenjoyable. Kids start out hating to go the doctor; aside from the slightly disturbed hypochondriacs, Munchasen’s Syndrome folks, etc. most people have to be trained by our system to demand and expect an open-ended schedule of testing, imaging, exams, visits, etc. in response to a first encounter with the medical system. Overcoming that hurdle is as important as getting out of the defensive medicine mindset on the part of the practitioners.

      • http://www.TheHealthCulture.com Jan Henderson

        Good point. Some of that training comes through advertising and is designed to make perfectly healthy people anxious, which in itself is not healthy. For example, the campaign that goes: “The early warning signs of colon cancer: You feel great. You have a healthy appetite. You’re only 50.” More at “Screening for cancer and overdiagnosis.” http://bit.ly/gWWaSN

        • Davis Liu, MD

          If Dr. Welch indicated colon cancer should not be screened, then that is very disappointing as there is evidence that found early does save lives. http://davisliumd.blogspot.com/2011/03/colon-cancer-screening-guidelines.html
          As you note in your link, it isn’t quite as clear with early stages of breast, prostate, kidney, thyroid, and skin cancer. There must be a balance in use of technology. Underutilization is just as problematic as overutilization.

          • stitch

            On the other hand, there are cost considerations to take into account. Screening for colon cancer with yearly hemoccult tests is rarely low cost, in and of itself. Screening with colonoscopy is expensive in terms of the test itself, but also in terms of the anesthesia and, at least in my area, the pre-op eval that is required because anesthesia is involved. That doesn’t even take into account the medical risks of the invasive procedure and the anesthesia themselves.

          • http://www.TheHealthCulture.com Jan Henderson

            Dr. Welch writes that overdiagnosis is not a major problem in cervical and colon cancer (unlike prostate and breast cancer). What’s overdiagnosed are precancerous abnormalities. About one in three adults have colon polyps. Not all of these are precancerous, but they are removed just in case (better safe than sorry). Once a patient has been found to have polyps, they are screened more frequently and more polyps are removed, the vast majority of which were never destined to become cancerous. So there’s an overdiagnosis of precancer.

          • http://www.TheHealthCulture.com Jan Henderson

            Stitch- Good point about the costs. Welch makes a good case for overdiagnosis, but it’s a sophisticated concept. His writing is very clear, and he’s addressing the general public, but I found myself needing to reread sentences several times and still feeling a bit fuzzy about the logic. The case he makes requires a certain comfort level with statistical and epidemiological thinking.

            He acknowledges the huge emotional element that patients bring to the issue (e.g., knowing someone (even a celebrity) whose life has been saved by screening). I’m not sure he’ll be successful in convincing patients of the harms of overdiagnosis. Not all doctors will agree with him. He may be ahead of his time.

  • http://www.TheHealthCulture.com Jan Henderson

    Another factor at work here in ordering tests and screenings is that, in some health care organizations, doctors are evaluated and graded on what they do. How can you measure real quality of care? You can’t. What you can do is count the number of tests and immunizations that are ordered.

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