Many doctors today are behaving inappropriately— I’m not talking about their bedside manner, but their test ordering habits. Recently, there has been a push to try and limit certain procedures and tests that do not benefit a patient’s health. At first this was mostly a way for the government and insurance companies to control costs; however, it has grown to become a quality and safety initiative (see “Choosing Wisely” below for more information).
The Issue
Today, many people are given tests they don’t need. One recent study showed that of all the people who undergo a first time cardiac catheterization (or angiogram) that less than a third actually went on to requiring angioplasty or coronary bypass surgery1! This means that two-thirds of the patients were exposed to radiation, had an invasive procedure, and didn’t need it. Those odds are worse than flipping a coin.
We are seeing this same phenomena in noninvasive testing as well, especially cardiac stress testing. More and more stress tests are being ordered, but less and less are abnormal. The percentage of stress test that are abnormal has dropped from 40.9% to only 8.7% over a 20-year period2. This may mean we are testing more and more lower risk patients who are the least likely to benefit from the test. Why is this happening? There are multiple reasons:
1. Fear of Lawsuits. Doctors want to protect themselves from ‘missing something’.
2. Patient Expectations. Patients in the USA typically feel that more care = better care.
3. Fee for Service Payment Model. Doctors get paid for doing things, not preventing them.
Why It’s Inappropriate
What’s the big deal if you have get a test and it turns out normal? You may not always recognize it, but there is a risk/benefit ratio for everything. Every test will at least cost you some time and probably some money. There is also some type of risk: pain with a simple blood draw, radiation exposure and increased future cancer risk, or more serious ones such as stroke, heart attack, or even death with an invasive procedure. Besides these concerns, there is also a potential complication that is not often talked about called the ‘slippery slope’. This is when one test leads to another, which then leads to a procedure that ends in a complication. Unfortunately, this often occurs in patients who did NOT need the first test to begin with.
The JAMA network has published a whole series of articles on this called “Less is More”. The initial case report for this series tells about a nurse who had non-cardiac chest pain that underwent a CT scan that was abnormal, then an invasive heart catheterization, where there was a major complication (a coronary dissection which is a torn vessel) that required emergency bypass surgery, and eventually cardiac transplantation! The sad part of this story is that she did not need any tests to begin with and that she had no blockages in her heart arteries!
Choosing Wisely
So what can the average person do about this? Well, the American Board of Internal Medicine (ABIM) along with Consumer Reports and almost every major medical society has joined together to form the “Choosing Wisely” initiative. They have complied lists of typically overdone tests and procedures by specialty and are asking both doctors and the patients to discuss the need to do them. This approach will hopefully foster more open discussion and a stronger doctor-patient relationship (aka therapeutic alliance). For more information check out: choosingwisely.org
Suppose you don’t have access to the net, or forgot to bring the Choosing Wisely list with you, what can you do? There are several simple questions that you can ask your doctor about the test that he/she is recommending for you:
1. Do I really need to get this done?
2. Will the results change what you will recommend for me to do?
3. What do you expect the test results to be? If normal, why get it?
4. What are the risks of the test itself and future tests/procedures it could lead to?
The vast majority of doctors mean well, but you still have to be your own health advocate. Any good doctor will not mind, nor be offended, if you question their advice.
Sources:
- Low Diagnostic Yield of Elective Coronary Angiography. New England Journal of Medicine. 2010.
- Temporal trends in the frequency of inducible myocardial ischemia during cardiac stress testing: 1991 to 2009. Journal of the American College of Cardiology. 2013 March.
