The hot news around the non-virtual water cooler this week has been the call by many physician professional organizations to reduce unnecessary medical tests and procedures. The move is aimed at lowering health care costs and improving decision making. The campaign, called “Choosing Wisely,” hopes to engage doctors and patients in a dialog around the procedures and tests.
In my experience, even the most educated patients are reluctant to go along with guidelines and evidence-based medicine, frequently demanding tests “just to make absolutely sure” that a problem doesn’t exist, or even worse, “because insurance will pay for it.”
I have had countless arguments with patients over all manner of tests and treatments. It’s difficult to help patients understand that medical testing isn’t entirely harmless. There is always the risk of a false-positive test that can result in further unneeded testing, stress, and potential harm. Radiation exposure is cumulative. Tests aren’t necessarily indicated just because a cardiology practice that owns a CT scanner is running radio ads that offer discounted cardiac risk scoring.
Many of the tests on the list are obviously questionable, yet patients consistently demand x-rays for low back pain. I have many colleagues who order colonoscopies every seven years for low-risk patients.
I’m sure many think this list will be helpful to stimulate discussion with patients, but I’ve tried the literature and data route before. Patients have accused me of trying to ration care when I’m simply following evidence-based guidelines.
Every patient has a story about something that “the doctors missed” and is afraid it will happen to them. There is also the subset of providers who don’t want to get caught on the wrong side of a lawsuit should something be missed.
A glance at my local newspaper today revealed four of five reader comments along the lines of, “The doctor didn’t want to do the test, but I demanded it and it saved me from a life-threatening situation.” I appreciate these individuals’ stories, but ordering every test on every patient every time is not only poor patient care, but a recipe for economic collapse.
The participating physician groups are partnering with Consumer Reports and AARP to get the word out, but I’m not sure it’s going to make a difference. As long as payers continue to cover some of these items (such as annual EKGs for low-risk patients without symptoms) it’s going to be an uphill battle.
Additionally, hospitals still often require some of these tests – such as a preoperative chest x-ray for all patients regardless of risk – making it difficult for physicians to just say no. The entire list of 45 procedures (each of the nine participating specialty groups identified five procedures that are overused) can be found online at Choosing Wisely.
From an EHR perspective, figuring out how to work clinical guidelines into real-world workflows and ensure truly usable clinical decision support is tricky enough when the guidelines are clear cut. When they’re not so clear (especially when you have multiple bodies recommending strategies which are contradictory, such as the mammography guidelines) it’s nearly impossible.
I’ve been asked by individual physicians to re-code clinical decision support during EHR go-lives because they don’t agree with the national standards. Indeed, we are in America, but as long as providers continue to have cowboy attitudes this will be a struggle. Similarly, the transition from “patients as patients” to “patients as consumers / customers” has also created difficulties. When physicians are graded on patient satisfaction scores, the decision to deny unneeded antibiotics or a requested test becomes more difficult.
I’m interested to hear how these recommendations have affected you. If you’re a physician or provider, are your patients hearing any buzz on this topic? And if you’re in IT or software support, are you receiving requests to modify clinical decision support to reflect constantly changing guidelines? Let me know what you think. E-mail me.