Inappropriate care requests: The role of health care professionals

Inappropriate care requests: The role of health care professionalsA guest column by the American College of Physicians, exclusive to KevinMD.com.

How to reduce the cost of medical care while improving quality is the focus of several initiatives, including the American College of Physicians’ High Value Care initiative, the ABIM Foundation’s Choosing Wisely campaign, and Consumer Reports’ Consumer Health Choices.

The common message is that we can improve the quality of care and lower costs by reducing the use of tests and treatments that provide little or no value to the patient and might even be harmful. Barriers to implementing recommendations on high value care include concerns about liability risk, patient demand (fueled in part by easy access to incorrect information online), lack of adequate time for physicians to talk to patients, and external pressures, including those from direct-to-consumer advertising and health reporting in the media. (For example, in a recent newscast in Rhode Island, an “expert” recommended that men over age 50 should undergo telomere testing.)

One source of external pressure to order tests or treatments that is cited less often is health care professionals themselves – not only physicians, but nurses, physical therapists, pharmacists, and others. Their well-intentioned comments or recommendations often result in unnecessary testing.

Examples of these pressures to test or treat occur frequently in my practice. At a routine follow up with a medical subspecialist, one of my patients mentioned that she had a backache. The subspecialist responded that she should make an appointment with me to get an MRI. Emergency rooms or urgent care centers often discharge patients with recommendations for tests that I should order.

Then there are the radiology reports in which the radiologist recommends a follow up study if a diagnosis is not clear after the original study or if they discover an incidental finding. How about the pharmacist who suggests that their customer with a cough call me so they can get a prescription for an antibiotic? And let’s not forget the health professional relatives and friends of our patients who suggest that they “ask their doctor to order” tests or treatments based on casual conversations at cocktail parties, sporting events, and family gatherings.

I realize that these suggestions are intended to be helpful, and in some cases, they are not recommendations but instances of thinking out loud in front of the patient. However, just as patients often interpret “this drug may cause cough and rarely causes death,” as “this drug will make you cough and will kill you,” when a health care professional says, “your doctor might want to consider ordering…”  the patient may hear “your doctor should order…” That puts the receiving physician, usually the primary care physician, in a difficult position.

While we may not be able to change the behavior of the trial lawyers, Internet “experts,” pharmaceutical companies, or the media, we can have an impact on our own actions and those of our fellow health professionals:

  • Physicians: if you believe that a patient needs a test or treatment, then order it yourself and take responsibility for all that goes with doing so. If you’re not sure, or don’t want to step on the primary care physician’s toes, discuss it with that physician. But don’t put the patient in the middle of it – that’s equivalent to stomping on toes.
  • Physicians: when we order an imaging study, provide enough information to allow the radiologist to interpret the test properly. Radiologists, if we order the wrong test for the clinical question, please let us know before the test is performed, not in the written interpretation. If you find something that may require further testing depending on circumstances, call us so we can discuss it rather than commit us to the test by recommending it in your report. (Ordering physicians, please take that call when it’s made or return it immediately if you cannot.)
  • All health care professionals: Let’s make sure whatever advice we give is within our level of training and expertise and the boundaries of our license.
  • Physicians: do not recommend tests or treatments to friends or family unless you have performed a proper evaluation (which is difficult to do over Thanksgiving dinner), and even if you do, be mindful of your colleague, the treating physician. It is OK to say, “I don’t know,” “I can’t give you advice without a more thorough evaluation,” or “It wouldn’t be appropriate for me to tell your doctor what to do.”

Another part of the solution is to reform the payment and delivery systems in ways that promote the provision of high value care. A system that supports the establishment of long-term trusting relationships between patients and physicians, that does not penalize for spending extra time talking to patients, and that encourages communication among health care providers will ensure that our patients get the tests and treatments that they need and are protected from those that are of little or no value.

Yul Ejnes practices internal medicine in Cranston, Rhode Island, and is the Immediate Past Chair, Board of Regents, American College of Physicians. His statements do not necessarily reflect official policies of ACP.

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  • http://www.facebook.com/people/Molly-Cooke/567191747 Molly Cooke

    Hi Yul – I struggle with the opposite issue with friends and family. I regularly hear about over-the-top workups that my contacts regard as examples of “really thorough care”. It feels disruptive to say “Your doctor did what?” Example: normal screening colonoscopy, followed by annual FOBT (why?), year three 1/3 cards positive (of course), leading to another colonoscopy, (surprise) normal again.

    • Yul Ejnes, MD, MACP

      Molly, you example illustrates an issue that could be the topic of a future column. What is the proper etiquette that a physician friend or family member should follow when they don’t agree with their friend’s or relative’s management, whether it’s that they’re getting too much, too littlle, or the wrong things? Sometimes it’s a matter of style or differing interpretations of the evidence. But what about when that management is seen as potentially harmful?

  • http://twitter.com/JohnWarePT John Ware

    How about adding this little bit of advice for physicians: Stop placing specious diagnositic labels, like “cervical degenerative disc disease” and “lumbar HNP” on the patients that you refer to me, the physical therapist, with a mechanical spinal pain problem. When the physician places this scary pathoanatomic label on the patient, then I’ve got to try to extract the thought virus that has him convinced his spine is going to fall apart or disintegrate when he moves a certain way.

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