Ask most patients, and they say their doctor has a good reason for ordering tests and prescribing treatments. Turns out their doctor may secretly disagree. That’s the conclusion of a new study. The implications are more than a bit disturbing.
Researchers from the Dartmouth Institute for Health Policy conducted a survey of more than six hundred physicians. Forty-two percent of family doctors admitted that patients in their own practice receive too much care – meaning that the doctor was ordering too many blood tests and x-rays and prescribing too many treatments. Only six percent said they were receiving too little. The study was published recently in the Archives of Internal Medicine.
The reasons why doctors would subject their own patients to too many tests and prescribe too many treatments were telling. Three out of every four MDs surveyed admitted that the most important reason why they overtreated their patients is that they were afraid of being sued for malpractice. In other words, they did the test because they were afraid they’d miss a serious diagnosis, something bad would happen to the patient, and then the doctor would be sued for not ordering the test. We call that defensive medicine. Just over half overtreated their patients because they believed that clinical practice guidelines told them to do so. Here’s a disturbing one: forty percent said they ordered too many tests as a substitute for not spending enough time with their patients.
This is a US study, which invites the usual comparisons to Canada. Since most MDs I know experience time pressure on a daily basis, I have no doubt that I and many of my colleagues are guilty of closing off prematurely an eight minute encounter with a patient by ordering a battery of tests.
Now, it’s true that Canadian MDs are less likely to be sued for negligence than American doctors. We’re catching up, but here’s the thing. You don’t have to be sued to practice defensive medicine! Just finding out you missed a life threatening diagnosis makes you overcompensate. If I fail to diagnose a pulmonary embolus – a blood clot on the lungs – I guarantee you for months afterwards, I’ll be checking for blood clots on every patient with chest pain and shortness of breath. It’s human nature. The other reason why Canadian MDs are just as likely – if not more likely – to order too many tests is that in Canada is that – as far as the patient’s concerned – there’s no financial disincentive to do so. They don’t pay for the tests, the province does!
What impact does unnecessary testing and treatment have on patients?
In their book Overdiagnosed, authors Gilbert Welch, Lisa Schwartz and Steve Woloshin talk about the all the medical diagnoses the average patient might receive if given a thorough physical — borderline hypertension, overweight, borderline diabetes, arthritis, and (for men) benign prostate enlargement. Overdiagnosis means you have all these labelled conditions even though you feel pretty good. The hazards of looking too hard for conditions or illnesses in healthy people, including additional procedures that carry no benefit but may cause psychological harm from being told you’re sick when you don’t actually feel that way, not to mention higher health care costs all around.
Given the risks, what should patients do when your doctor suggests doing a test?
When a specific test is being offered or suggested, ask why your doctor is recommending it — that may lead to an interesting discussion. A non-confrontational way to do that is to ask how the test result will affect the management of your condition. That will lead your doctor to talk about the treatment plan, assuming of course that there is one.
The other important person to speak with is you. Ask yourself how you feel about this issue. Some people want their doctor to look for potential medical problems down the road to try and head them off. To them, this isn’t overtesting but appropriate testing. Other people may feel they’re well as long as they feel well not to bother getting screened and tested for everything. If you refuse testing, you need to accept the fact that perhaps you’ll miss some benefit of finding something early.
A middle ground might be to get the test but decide later on whether or not to react to the test results.
Welcome to the world of medical uncertainty. There is no one right answer to this dilemma. Health care providers practice with uncertainty all the time. As a partner in your own wellness, at times so will you.
One more word of advice. Don’t accept a bunch of tests in lieu of a thorough history and physical. There is no substitute to listening to the patient.
Adapted from a blog post that appeared on White Coat, Black Art.
Brian Goldman is an emergency physician in Canada and author of The Night Shift: Real Life In The Heart of The E.R., published by HarperCollins.
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