The impact of unnecessary testing and treatment on patients

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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  • Anonymous

    The top 2 reasons why health care costs so much in North America:
    1.  Malpractice risk.
    2.  Patients have little personal cost because of health insurance.

    Insurance should have high deductibles to reach.  If every prime rib only cost $1.50, do you think people would mostly buy hamburger?
    Get the attorneys out of the system.  Develop something else, either medical courts or loser pays, but do something to stop the madness of patient’s and families disappointments and anger that “someone is at fault.”

  • http://www.facebook.com/people/Craig-Koniver/100001463176810 Craig Koniver

    Great points here. I think what drives a lot of test ordering and prescription writing, in addition to the reasons you listed, is the belief by many doctors that this is the “type” of care patients want. The idea is that the patient is sick and needing something from the doctor. That something is believed to be more data (labs, radiology tests), prescription medicine, or surgery. But in reality, most patients just want to be listened to and validated and want to connect with their doctor. But somehow we as physicians have turned what patients want into something we can order when in fact, it would do us all good to throw away that type of thinking and just be there for the patient–taking our time to listen and connect.

  • Anonymous

    The impact: some patients will think you really care, and some patients will work out what’s happening and lose trust and respect, perhaps after a painful and upsetting unnecessary biopsy or procedure. 

    I worked out very early you have to maintain some control in the consult room. It’s important to find a doctor who’ll work with you, not just dictate what you will and won’t have…the power dynamic in the consult room needs to be considered.
    Sadly, I don’t think we can trust doctors any more to have our best interests at heart – are they getting a royalty for selling me that hip joint or a target payment for cancer screening? Is this test an example of defensive medicine – is it in his/her best interests, not mine?
    Personally, I believe many doctors have sold out on their patients, who should come first…and I understand the problem in the States with the threat of litigation hanging over your heads. It does make it difficult, but a solution must be found – what about asking patients to sign-off if they decline tests and exams? Or, suggest things you might order, what they might achieve and how they might harm and leave it to the patient. I think empowering the patient may be part of the answer rather than the doctor deciding or doing everything “just in case”. 

    I know American women often face coercion in the consult room – forced into unnecessary and potentially harmful exams and elective cancer screening to get the Pill and other meds. I wouldn’t accept that situation – it’s harmful – emotionally and physically, disrespectful and unethical. It has turned many of your women off doctors and some have lost respect for the profession. Some now use the internet, see a doctor while they’re overseas or avoid doctors altogether…that shouldn’t be necessary. This coercion does not improve healthcare for women, it’s bad medicine.

    We have issues in Australia too, but you can still find a GP who’ll respect your right to make an informed decision about screening, testing etc….you can work with the doctor.  My GP has simply made a note on my file that I’ve made informed decisions about cancer screening.
    I think it’s quite dangerous to be passive and compliant in the consult room – if a doctor tried to pressure, intimidate or coerce me into testing or an exam or wouldn’t listen to me – I’d leave and find someone else….for the sake of my health. I should add “I’ve” made decisions about screening and I accept full responsibility for those decisions. At the moment the information patients often receive about screening is misleading and incomplete and doctors know their patients can’t really make an informed decision, so everyone gets pushed into screening – if patients are provided with a balanced overview, they CAN make informed decisions. You can also note any recommendation made by your  doctor, check it out and get back to her at the next consult. I had the CA-125 blood test tacked onto some of my blood work – I noticed, did my reading, was horrified and told my GP at the next consult that I didn’t want to hear the result and did not want it tacked onto any future blood work – that has been duly noted.

    • Anonymous

      Good for you–but not everyone is “you.”  I’ve gone through careful, detailed discussions about the options, risks, and benefits of various tests or treatments only to be met with “well, whatever you think is best–you’re the doctor.”
      There’s something behind that gesture of trust.  Part is fear, part is realizing that the doctor has years of training and insight that a 15 minute discussion will not duplicate.  And part may be to put all the glory, or blame in some cases, on someone else.