EMRs make it easier to just order the test

The discourse on the problems of the modern healthcare system contains much vitriol and blame. There is a distinct flavor of adversarial combat in the discussion; pitting physicians, those in the trenches, with those politicians and lawmakers on the other side. With estimates of healthcare costs exceeding 15% of the gross domestic product of the United States, it is easy to understand the passion that the topic evokes. The complexity of the problem resists simple solutions. There is no Occam’s razor that can cut through the debate and illuminate the way forward.

So often, when the topic of unnecessary medical testing arises, it is a further demonstration of this antagonistic relationship inherent within the debate. Doctors, the prevailing wisdom goes, are forced to order all of these tests because of the legal climate we practice in. There is little room to walk to your car at the end of a shift with all of the lawyers that are roaming the landscape. This would seem to be a contradiction to everything already stated — that one easy problem in the healthcare quagmire that begs an easy fix. If only there would be regulation and caps on malpractice and torts, unnecessary testing would be largely fixed. With the full realization that the plural of anecdote is not data, let me argue for a different point of view.

The prevalence of electronic medical records, or EMRs as they are commonly known, has lead to an unprecedented ease in procuring a medical test. With a flurry of right clicks, I can order a full battery of tests feeling secure that I will get to the bottom of this patient’s ill humors. But is this a good thing? Is the convenience of having the thyroid-stimulating hormone test right below the complete blood count and the complete metabolic profile a benefit to our patients and our overall system? Regardless of clinical indication, I can cast as wide a net as possible in order to snare that zebra fish. Keeping in mind the danger of specifics to illustrate the general, let me discuss a few recent examples that came up during my own clerkships.

A patient recently came into the inpatient psychiatric ward with multiple delusions. Most pertinent to this discussion, this patient was convinced that she was pregnant. When a patient states they believe they are pregnant, we do not often paint this as a delusion. But with this patient, who was a male-to-female transgender, it was biologically impossible. Presented without further discussion on rounds, her belief was immediately labeled a delusion — and rightfully so. But against all sound reasoning, a pregnancy test was ordered. When asked, the attending would say that it was to reassure the patient; when pressed further, it was admitted that it was just easier to order the test than it was to have to really get to the bottom of this delusion.

This extreme example illustrates our own blame within the system. Many times we protest that we are ordering these tests we know to be unnecessary to escape the specter of some legal action. Perhaps there is sometimes a more innocuous explanation. Namely, it is sometimes just easier to click “order.” Faced with increasing time constraints, growing patient lists, and the demands of multiple responsibilities, ordering a test means little to me in terms of real opportunity cost. When I am presented with a menu of options for the latest and greatest in medical testing, I do not see the associated costs of ordering that extra anti-nuclear antibody test. With these costs hidden from my own sight and mind, it is often easier to order the test, but that says nothing about whether or not it was right to do so.

Corbin Rayfield is a medical student and can be reached on Twitter @CorbininChicago.

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  • Tiredoc

    If the pregnancy test wasn’t ordered, then you couldn’t have found that teratoma, could you?

    I hear this over and over. “Ordering too many test is why we’re so expensive.” It isn’t true. Tests are cheaper than consults. Training and brains are more expensive than chemistry. In hospital laboratories, the cost of the equipment is high, but running the tests themselves is not, particularly if the lab is not running at capacity.

    Personally, I wouldn’t think telling the patient that they’re delusional would accomplish much either. Standard of care for delusional stroke patients is to treat them like the stroke is real until they’ve made their miraculous recovery and go home.

  • azmd

    “Getting to the bottom of the delusion?”

    I would be interested to hear a little more about how you think this could be done, how it could be helpful to the patient, and whether you took it upon yourself to try. That might have been a bit more valuable learning experience for you than cross-examining the attending about a lab he or she ordered, then criticizing the patient’s treatment in a blog post.

    • http://onhealthtech.blogspot.com Margalit Gur-Arie

      …and I am also not sure how it’s easier to order a test in the EMR with a “flurry of right clicks” than to just order verbally…

      • azmd

        Probably it isn’t. But then there would be no premise for a catchy blog post, and no “social media presence” which as we all know appears to be critically important to being a good doctor these days…

  • T H

    There are crazy people with real disease. I have even been known to tell my admissionist “CWRD” when they look at me with question marks hovering over their heads. The 45 year old drug seeker who complains of chest pain in order to get an ED bed quickly sometime ACTUALLY has chest pain.

    Ordering a cardiac marker series and an EKG is a lot easier on my conscience than missing an MI or fatal arrhythmia. Cost? My conscience is worth more to me than the tax dollars/insurance dollars I just spent.

    Other parts of ordering tests:
    > Histories miss things – or we misinterpret what we hear. Testing covers that.
    > Many of the things we learn about physical exam have low sensitivity, even in practitioners who have been in their specialty for a couple decades. Not all AAAs have pulsatile midline masses (or the patient perhaps has a habitus that makes proper palpation difficult). Testing can help cover that.

    If we don’t look, we don’t find: and that is a dis-service all on its own.

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