by Carole Jackson, Bottom Line Health
Itâs not easy being a doctor. Often itâs like being a detective and needing to find the right clue that will solve “the case.” Doctors know that some of their decisions are life or death, but they donât always know which ones. So it makes sense, theoretically, to err on the side of caution and order more tests and make more referrals rather than lessâ¦ or does it? A new survey reports that even doctors think that some of those tests and referrals are unnecessary — and even potentially hazardous.
According to a survey of 627 randomly chosen doctors nationwide that was created and administered by MDs from Dartmouth Medical School in Hanover, New Hampshire, and the Veterans Affairs Medical Center (VAMC) in White River Junction, Vermont, one in four primary care physicians acknowledged practicing medicine too aggressively — meaning that he/she had ordered more tests or made more referrals than he thought were necessary. The findings were published in the September 26, 2011 issue of Archives of Internal Medicine.
WHATâS UP WITH THAT?
I spoke with one of the lead researchers, Brenda Sirovich, MD, an associate professor of medicine at Dartmouth and an internist at the VMAC, who told me that this study demonstrated that there is often “a message in medicine that more is better” — but not necessarily because it leads to better patient care. In the survey, these were the most common reasons cited by doctors (in order) for their overzealous efforts…
1. Fear of a lawsuit. “Doctors perceive that itâs easy to be sued by a patient for not ordering a test or making a referral — so the more tests you run and referrals you make, the assumption is, the less likely you are to suffer litigation,” said Dr. Sirovich. And itâs a valid fear for physicians to have: Three out of four doctors in “low-risk” specialties (such as family medicine, pediatrics and psychiatry) will be sued for malpractice by age 65 — as will 99% of doctors in “high-risk” specialties (such as neurosurgery and thoracic-cardiovascular surgery), according to a study published in the August 18, 2011 issue of The New England Journal of Medicine.
2. Process drives their practice. Physicians are increasingly encouraged to complete “checklists” so that the performance of the physician, the practice and/or the hospital system can be monitored by an employer, an insurance company and/or a government agency. The checklists often contain tests (or diagnoses that need to be ruled out by the tests). The goal of having checklists is to standardize processes across physicians and practices in order to improve the quality of care, said Dr. Sirovich. But some doctors feel boxed in by these checklists, since their instincts and experience become less important than following the rules.
3. An assembly-line approach. Doctors have such a limited amount of time with each patient that, instead of asking more questions that could lead to a more accurate diagnosis or discussing all the multiple treatment options, Dr. Sirovich said, they usually conclude, “Letâs refer you to a specialist” or “Letâs run some tests.”
4. Tests sometimes make doctors money. The doctors in the survey acknowledged that money, not quality of care, is occasionally a factor, too. Only 3% admitted that financial considerations influenced how they practiced, but 40% said that they thought that other primary care physicians would order fewer tests if those tests didnât provide any extra income.
NOT A “BEST PRACTICE”
We all want thorough doctors who weigh all possible causes for the symptoms that brought us to their offices, so whatâs wrong with a few extra tests? After all, if your doctor isnât 100% sure of a diagnosis, donât you want him to be certain? Sure, there are potential benefits to having extra procedures — but itâs important to realize that there are also potential risks.
For example, one problem is that an unnecessary test could lead to a false-positive, meaning that youâre initially diagnosed with — and even treated for — a condition that turns out to be nothing. The test that led to the false-positive result might have exposed you to risk, such as radiation (not to mention unnecessary anxiety) — and it might also lead to a cascade of more unnecessary tests. On top of all that, the tests are likely to cost you — and certainly the health-care system — more money.
ASK LOTS OF QUESTIONS
So what should a well-informed patient do to combat this potentially dangerous reality? Donât automatically accept a test. Itâs okay to question your doctors, making sure that they cover the following points…
- â¢ Why do I need this test? You doctor should offer a clear explanation of why you need it, matching your symptoms with the test.
- â¢ Would you have this test if you were in my situation? This may lead your doctor to stop and think more carefully about the recommendation.
- â¢ Are there other options? Ask your doctor to enumerate them and explain why he or she is recommending this particular option for you.
- â¢ Is waiting an option? Does your doctor think there will be harm in waiting some period and then reconsidering the test?
- â¢ What are the potential risks and benefits of the test? Know all the pros and cons before you agree to anything.
Most importantly, all of us need to have a two-way dialogue with our doctors. In their time-pressured haste, many doctors donât take the time to ask a number of questions about their patientsâ lifestyles that might uncover critical information that could lead to a more accurate diagnosis, test or treatment. If your doctor asks you only about symptoms and then goes straight to testing — without asking about what you eat, how active you are, where you have traveled, etc. — then you may want to consider changing doctors. Doctors need to be treating you, the patient — not just the stats in your patient chart.
Brenda Sirovich, MD, associate professor of medicine at Dartmouth Medical School, Hanover, New Hampshire, and an internist at the Veterans Administration Medical Center in White River Junction, Vermont.