ACP: 5 excuses physicians and patients should question

ACP: 5 excuses physicians and patients should questionA guest column by the American College of Physicians, exclusive to

Whether we call them “unnecessary,” “not indicated,” “inappropriate,” or “overused,” certain tests and procedures add little or no clinical benefit to patients and in some cases they cause harm. They also contribute to the cost of care without improving care. At a time when payers are challenging payment for legitimate services that patients need, the medical profession should lead the way in reducing the wasteful medical care over which they have control.

On February 21, Choosing Wisely, an initiative of the ABIM Foundation, announced the participation of 17 additional medical societies, each of which released a list of five commonly done tests or procedures whose use should be questioned by physicians and patients. ACP was one of the first groups to release a list in April 2012, and prior to that established its High Value Care initiative that shares the goals of Choosing Wisely. More societies will publish their own lists later this year.  I won’t describe the items here but suggest that you read them on the Choosing Wisely webpage.

In the spirit of the Choosing Wisely campaign, I would like to add my own list of five items. These items are not tests or procedures, but excuses that physicians and patients should question. They are reasons that some physicians raise for not following recommendations such as those in Choosing Wisely. I came across all of these following the recent ABIM Foundation announcement.

Here is my list of five commonly-used excuses for not implementing recommendations for high value care:

1. We can’t follow these recommendations without tort reform. This is probably the most widely-used excuse and my favorite. Whenever a study or guideline advises against doing something, we hide behind the lawyers to justify not changing our ways. The logic goes something like this: if we don’t do the unnecessary test and something bad happens to the patient, then we will be sued. That argument has a few holes in it. We’re not talking about the capricious omission of recommended testing here but avoiding tests for conditions that are very unlikely to be present, tests that may create a problem where one didn’t exist.  In addition, the excuse ignores the other side of the argument. If a patient experiences a complication from a procedure that was not necessary (think contrast reaction during a CT to follow up on an incidental finding) will the lawyers give you a free pass because you were “being thorough?”

2. These recommendations are another step towards rationing. High Value Care, Choosing Wisely, and all of the similar initiatives that preceded them focus on potentially unnecessary testing and procedures that may harm patients without benefitting them. How is not performing a risky test that won’t help a patient (or might even hurt them) rationing?

3. The government should leave us alone and let us practice medicine. This is a variation of the same conspiracy thinking that gave us “death panels.” The “government” is not telling us what to do or not do. The conversation about the appropriateness of testing and procedures started long before the government started talking about the cost of medical care. It is a fundamental part of what we teach medical students – it was in the medical curriculum when I was a student in the 1980s. Our profession is leading the discussion because that is what a true profession does.

4. These recommendations are just another insurance company gimmick to save money. While insurers (and employers, for that matter) are supportive of these efforts and may see a decline in their health care costs, they are not the driving force behind these campaigns. As noted above, the medical profession is leading this movement. When I read or hear this excuse, I sometimes wonder if some of the resistance to these recommendations is driven by concerns about loss of income.

5. I know what my patients need and don’t need a group of ivory tower-types telling me what to do. I call this the “ego excuse.” The physician groups that make these expert recommendations include members from a variety of practice settings, including private practice. And they are recommendations, not commandments. They are a call for all of us to pause and ask the simple questions of “Is this test or procedure really necessary?” and “Will it improve the health of the patient?” This excuse ignores a fundamental principle of being a profession, which is that of self-evaluation of what we do as physicians.

One organization submitted a second list of five items in the recent Choosing Wisely release.  I could probably release a second list of five excuses. Perhaps I will in a future post. Then again, we may even see some of them in the responses to this post.

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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  • keith zadock

    Blame it on the Government and socialisim

  • doc99

    Patient satisfaction surveys?

    BTW Med Mal is complicated because practice patterns are often the result of natural selection and not so easily unlearned, especially if clinical acumen suffers from disuse atrophy.

  • Margalit Gur-Arie

    Any advice for the esteemed physicians employed by centers of excellence that advertise for and provide Executive Physicals?

  • Jason Simpson

    “If a patient experiences a complication from a procedure that was not necessary (think contrast reaction during a CT to follow up on an incidental finding) will the lawyers give you a free pass because you were “being thorough?”

    No, but they are more likely to sue you if you miss something that could have been caught on an “unnecessary” test.

    Ask your lawyer colleagues — they’ll tell that that the vast majority of med mal suits are brought over “failure to diagnose” rather than “complication from test or treatment”

    • Yul Ejnes, MD, MACP

      I’m on the Board of the state medical society’s insurance brokerage so I know a bit about med mal trends. And while “failure to diagnose” is a common reason for lawsuits, it’s “failure to diagnose” as in not sending a woman with a palpable breast mass and a negative mammogram to a surgeon for further evaluation, not following up on abnormal test results, or not getting an EKG on a 70 year old smoker who gets heartburn when he climbs a flight of stairs. Not diagnosing a problem because you didn’t order a test that was not indicated may generate a lawsuit, as might any bad outcome, but that physician will have followed the standard of care, which would be a strong defense, as opposed to the other examples that I listed.

      To say that we should keep performing tests and procedures on patients, even if they are of little or no value to that patient, because there’s an ever-so-minute possibility that we might get sued if we don’t, puts our irrational fears ahead of the patient’s real needs.

  • Yul Ejnes, MD, MACP

    I find it amusing that you characterize my arguments as “logical fallacies,” then proceed to refute them with logical fallacies of your own. In many ways your arguments support the theme of my post and provide a few more excuses for my list, such as “‘Unnecessary’ is in the eye of the beholder,” “If we don’t test we’ll do poorly on our report card,” and the corollary to “Spending lots of money on Powerball tickets is a good idea because sometimes people win.”

    • William Sullivan

      I find it amusing that you summarily dismiss the issues I raised without responding to them

      Defining what is meant by the terms you use isn’t a logical fallacy, it’s grade school science. Yet you refuse to do it. The ACP bases one of its recommendations on shaky scientific findings. And all you can do is mock me for demanding more scientific rigor from you and your organization.

      A fear of legal liability is pervasive throughout our medical system and often does lead to low yield testing. On one hand you recommend that doctors take your advice not to test, comparing the chances of being sued to the chances of winning the Powerball (which is 1 in 176 million and would equate to less than 10 malpractice lawsuits filed nationally from the 1.5 billion or so doctor-patient interactions each year). On the other hand, you refuse to indemnify physicians for following your recommendations because you are apparently afraid of being liable yourself. Can’t you see the hypocrisy in your position? Or don’t you care?

      It’s unfortunate that you have to resort to making light of a discussion on this serious topic, but I suppose that’s all you can do when you aren’t able to respond to the issues.

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